Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514).  
 
You asked the Plan to pre-approve percutaneous vertebral augmentation. You say that the enrollee has failed 
conservative management for acute compression fracture.  The Plan denied your request. The Plan says the 
enrollee's current back pain is not primarily due to the identified acute or subacute VCFs and does not have 
severe, debilitating back pain requiring hospital services.  
 
The Plan follows Medicare rules. Medicare rules say that percutaneous vertebral augmentation is covered when 
the criteria listed in the 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 percutaneous vertebral augmentation. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found that the notes 
show the enrollee has had pain since a fall in March, indicating that this is not an acute or subacute fracture, 
despite the magnetic resonance imaging (MRI) noting it was an acute compression fracture. The documentation 
does not support the progression of vertebral body height loss or a severe impact on his daily functioning. 
Additionally, the findings corroborate other plausible causes of his low back pain. There is noted retropulsion 
of the posterior superior endplate and mild canal stenosis. Therefore, the enrollee does not meet the coverage 
criteria listed in the LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous vertebral augmentation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve percutaneous vertebral augmentation (22514).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (G0151, G0153, G0157, G0299, 
Q5001) provided on May 29, 2022, to July 27, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is May 29, 2022. The NOA was not received by the Plan until August 19, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services (G0151, 
G0153, G0157, G0299, Q5001) provided on May 29, 2022, to July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you would like your insurance to cover the 
request due to issue you have developed and you cannot afford to pay for dentures yourself. 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. This benefit includes the 
requested complete denture - mandibular (D5120) but is limited to complete dentures (upper and lower) or 
Partial dentures (upper and lower) one upper complete/partial and/or one lower complete/partial denture every 
five calendar years, including routine post-delivery care, includes necessary extractions to fit dentures 
(unlimited). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received covered lower partial denture (D5214) on December 9, 2021. Although these are two 
different services, they fall within the same category in your Evidence of Coverage and are subject to the same 
frequency limitations. Therefore, this benefit was exhausted as of December 9, 2021. Therefore, we decided 
that the Plan does not have to pre-approve a complete denture - mandibular (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on March 
2, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 January 19, 2023. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on March 2, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 72 visits of physical therapy (PT) services. 
 
You asked the Plan to pre-approve the PT services. You say that the continued services are medically necessary 
to help you with your complex needs. The Plan denied your request. The Plan says you and your care giver 
have had enough time to learn a home program so you can practice your skills. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the PT services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have chronic functional loss and require a repetitive exercise 
program. You have marked inability to respond to skilled therapy. You can continue with a repetitive exercise 
program and do not require unique input from a skilled therapist to participate in or maintain an exercise 
program. 
 
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 PT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 72 visits of physical therapy (PT) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder triage test (81479) provided on October 13, 
2022.  
 
You asked the Plan to pay for the Cxbladder triage test. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says this testing is experimental/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 pay for the Cxbladder triage test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the standard of care for this condition is cystoscopy, cytology, and imaging. The 
provided documentation did not show that these were performed or why Cxbladder is more appropriate or more 
effective at leading to an improved outcome than the standard of care for this enrollee. This is based on current 
guidelines and evidence. There is insufficient evidence to support Cxbladder as a first line testing method over 
current standards of care. Therefore, this request for such will be considered not medically necessary 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 Cxbladder triage test have not been met. Therefore, we decided that the Plan 
does not have to pay for the Cxbladder triage test (81479) provided on October 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator.  
 
You asked the Plan to pre-approve a home ventilator. You say that the records provided support the need for a 
home ventilator. The Plan denied your request. The Plan says a home ventilator is not medically necessary.  
 
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. 
 
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 criteria for coverage have not been met.  Our physician reviewer found a home ventilator is not medically necessary.  This enrollee has severe COPD and was recently hospitalized with pneumonia and acute 
on chronic hypercarbic respiratory failure.  The enrollee improved with bilevel positive airway pressure 
(BiPAP) in the hospital.  This enrollee may benefit from BiPAP with average volume assured pressure support 
(AVAPS) during sleep as an outpatient.  The medical record does not indicate this has been tried and shown to 
fail as an outpatient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit and cone beam computed 
tomography (CT) scan (99204, D0367, 99212) provided on October 7, 2022, to December 15, 2022. 
 
You asked the Plan to waive the copayment for the office visit and cone beam CT scans. You say that the 
services should be covered as you disagree with the charges. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. Coverage for the cone beam CT scan denied correctly as it does not fall 
within your dental benefits. 
 
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 $15 
copayment for Physician/Practitioner services, including doctor's office visits.  
 
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. 
 
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 a $15 copayment for the office visit. This item/service falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the office visit provided on October 7, 2022, to December 15, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the records provided support the need for a 
home ventilator. The Plan denied your request. The Plan says a home ventilator is not medically necessary.  
 
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. 
 
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 criteria for coverage have not been met. Our physician reviewer found a home ventilator is not medically necessary.  The medical record for this enrollee includes a few progress notes from a recent 
hospitalization, including an arterial blood gas that shows mild carbon dioxide (CO2) retention.  A diagnosis of 
"restrictive thoracic disease" is mentioned, and undated spirometry results show a forced expiratory volume in 
the first second (FEV1) of 32% of predicted with a normal FEV1/forced vital capacity (FVC) ratio, but a poor-
quality test.  There is no mention in the record of chest or spinal deformity.  There is no diagnosis of 
neuromuscular disease or COPD.  The enrollee is obese with a weight of 242 pounds.  There is no 
documentation of chronic CO2 retention with an arterial blood gas (ABG) done while stable.  If that is present, 
the patient may benefit from bilevel positive airway pressure (BiPAP) during sleep as an outpatient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you live alone and do not have care at home.  The 
Plan denied your request. The Plan says SNF care is not medically necessary. 
 
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 clinical documentation shows that you have met all inpatient therapy goals 
(ambulating more than 300 feet and self-care tasks with supervision). No daily skilled nursing needs are 
specified, and clinical documentation does not show that you require daily skilled services. From a practical 
standpoint, clinical documentation does not show that you require daily skilled services on an inpatient basis in 
a SNF. 
 
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 skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the records provided support the need for SNF care.  
The Plan denied your request. The Plan says the criteria for coverage have not been met.  
 
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 while the enrollee has skilled therapy and skilled nursing needs, they have met all 
inpatient therapy goals and this skilled care is not required on a daily basis. The clinical documentation 
provided does not show that the enrollee requires continued daily skilled services on an inpatient basis in a 
SNF. 
 
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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) 
device (E0730). 
 
You asked the Plan to pre-approve a TENS device. 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 the TENS is a type of electrical nerve stimulator that 
is employed to treat chronic intractable pain. 
 
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 TENS device. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found this therapy is specifically excluded for 
treating low back pain if you are not enrolled in a clinical trial of TENS. 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 a TENS device have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a transcutaneous electrical nerve stimulation (TENS) device (E0730).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lens index, the ultraviolet lens, the anti-reflective coating, 
the deluxe lens feature, and the progressive lens provided on February 7, 2023. 
 
You asked the Plan to pay for the lens index, the ultraviolet lens, the anti-reflective coating, the deluxe lens 
feature, and the progressive lens. You say that the provider did not inform you that the lens enhancements 
would not be covered. The Plan denied your request. The Plan says the services were not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan does not cover enhancements. 
 
We looked at the file and the Plan's rules. Specifically, enhancements are not covered services and these 
services are considered enhancedments. Based on this information, we decided that the Plan's rules for 
coverage of the lens index, the ultraviolet lens, the anti-reflective coating, the deluxe lens feature, and the 
progressive lens have not been met. Therefore, we decided that the Plan does not have to pay for the lens index, 
the ultraviolet lens, the anti-reflective coating, the deluxe lens feature, and the progressive lens provided on 
February 7, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from January 29, 
2023, to January 31, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you should not be responsible for the 
cost share because the facility made you stay extra days. 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 $0 
copayment for days 1 to 20 and a $184 copayment per day for days 21 to 100 for SNF care.  
 
 You have been asked to pay $522 for a SNF stay ($184 per day x 3 days = $522). This item/service falls within 
the SNF care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for a SNF stay provided from 
January 29, 2023, to January 31, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lemtrada. 
 You asked the Plan to pre-approve Lemtrada. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Lemtrada. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drug. There is no documentation provided indicating that the plan's required drug would likely be less 
effective and/or likely have adverse effects 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 Lemtrada have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lemtrada.