Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the abdomen/pelvis. 
 
You asked the Plan to pre-approve the CT scan. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they 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 CT scan. Our reviewer says that the 
requested CT scan is medically reasonable and necessary. Our physician reviewer found that the requested CT 
was meant for follow-up of an old CT scan, which showed possible pancreatic mass. With suspicious finding in 
scan from the prior year, the requested CT scan is indicated to look for a change in the area of suspicion in the 
pancreas. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan of the abdomen/pelvis.  
 
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 additional non-emergency medical transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says you have exhausted this benefit. 
 
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 Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 6 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency medical transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a knee orthosis with flexion and rotation control (L1852, 
L2425, L2780) provided to the enrollee on . 
 
You asked the Plan to preapprove the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the request is not medically necessary because your records show you do not have recent 
injury or surgery or objective evidence of instability. 
 
The Plan must follow Medicare rules. Medicare rules say that knee orthoses defined by code L1843 are 
covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s) or when knee 
instability is documented by examination of the beneficiary and objective description of joint laxity. The record 
sent by the provider indicates knee pain but the records do not demonstrate recent injury or surgery or that 
instability of the knee was found on physical exam. Therefore, we decided that the Plan does not have to 
preapprove a knee orthosis with flexion and rotation control (L1852, L2425, L2780) provided to the enrollee 
on .
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crowns (D2740), core buildup (D2950) and crown 
repair (D2980). 
 
You asked the Plan to pre-approve the crowns (D2740), core buildup (D2950) and crown repair (D2980). You 
say that per the fee scheduled, these are allowed per year. The Plan denied your request. The Plan says the 
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 Plan's 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 pre-approve the 
crowns (D2740), core buildup (D2950) and crown repair (D2980).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions (D7310) 
for the lower left quadrant, an extraction (D7210), relaxation gas (D9230), and drugs and medicaments (D9630 
x 2). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says drugs and medicaments are not listed as a covered service. The Plan 
also says referrals for specialist services are required from your general dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the drugs and medicaments are not 
among those covered under this benefit. Additionally, the provider in this case is not a general dentist. 
Therefore, we decided that the Plan does not have to pre-approve alveoloplasty in conjunction with extractions 
(D7310) for the lower left quadrant, an extraction (D7210), relaxation gas (D9230), and drugs and 
medicaments (D9630 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the gum surgery for restorative procedure (D4212) for 
tooth #2. 
 
You asked the Plan to pre-approve the dental service. You say that the requested service is necessary and 
therefore should be covered. The Plan denied your request. The Plan says gum surgery for restorative 
procedure is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's 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 pre-approve the 
gum surgery for restorative procedure (D4212) for tooth #2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested oral sleep apnea appliance. 
 
You asked the Plan to pre-approve an oral sleep apnea appliance. The Plan denied your request. The Plan says 
the requested equipment can be provided in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 has network providers 
available who can provide the item at issue in this appeal. We found no exception that would require the Plan 
pre-approve the item. Therefore, we decided that the Plan does not have to pre-approve the requested oral sleep 
apnea appliance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for chronic illness 
including allowance for food/utilities, transportation for non-medical needs, and home assistance services. 
 
You asked the Plan to pre-approve special supplemental benefits. You say that you have ulcerative colitis and 
nutritional food is very costly but would help your health and recuperation from your condition. The Plan 
denied your request. The Plan says the denial of authorization for these benefits is correct, because you do not 
have an eligible condition for these benefits. 
 
The Plan must follow Medicare rules. Medicare does not cover custodial care services. The Plan has a 
supplemental benefit for coverage of food, utilities, non-medical transportation, and home assistance services 
for enrollees with certain eligible conditions that meet the criteria described in the previous section. 
 
We looked at the file, Medicare rules, and the Plan's rules. The condition you are requesting coverage for is not 
among the specific eligible chronic conditions for which these supplemental benefits are covered. Based on this 
information, we decided that the Plan's rules for coverage of special supplemental benefits have not been met. 
Therefore, we decided that the Plan does not have to pre-approve special supplemental benefits for chronic 
illness including allowance for food/utilities, transportation for non-medical needs, and home assistance 
services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says you do not meet criteria for the requested items. 
 
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.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve adult day care services. 
 
You asked the Plan to pre-approve the adult day care services. You say that you would like reconsideration 
because these services are medically necessary. The Plan denied your request. The Plan says these services are 
not covered under the member's Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the adult day care services have not been met. Specifically, Medicare does not cover custodial care. 
Therefore, we decided that the Plan does not have to pre-approve adult day care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you originally received temporary dentures 
due to your gums being swollen. You say that you were advised you would later receive permanent ones. You 
say that you never did. You also say that you are unable to eat and experience gum pain. The Plan denied your 
request. The Plan says dentures are covered once every 5 plan years. The Plan also says the frequency limit has 
been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and dentures are a covered service, the 
frequency limit of once every 5 plan years has been reached. The record shows that the Plan previously paid for 
dentures that you received on November 13, 2018. Therefore, we decided that the Plan does not have to pre-
approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Computed Tomography (CT) of the Lumbar Spine (72131). 
 
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they 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 CT scan. Our reviewer says that the 
CT scan is medically necessary. Our physician reviewer found the enrollee has persistent back pain. The 
enrollee is unable to tolerate NSAID therapy and has failed steroid injections twice. The CT scan is 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 the CT scan have been met. Therefore, we decided that the Plan has to pre-
approve Computed Tomography (CT) of the Lumbar Spine (72131).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a referral to see a dermatologist. 
 
You asked the Plan to pre-approve a referral to see a dermatologist. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the requested services are not 
medically necessary. 
 
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 a referral to see a dermatologist. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found you have a diagnosis, condition, and/or symptoms that meet the Medicare 
criteria for coverage of authorization to see a dermatologist. The authorization to see a dermatologist is 
considered the standard of care for the treatment of your condition. You were noted to have clinically 
premalignant lesion of actinic keratosis, which may represent skin cancer and need a specialist to differentiate. 
Therefore, you meet criteria for the requested services. 
 
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 referral to see a dermatologist have been met. Therefore, we decided that the 
Plan has to pre-approve a referral to see a dermatologist.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI, breast, without and with contrast material(s), 
including (CAD real-time lesion detection, characterization and pharmacokinetic analysis), when performed; 
bilateral (CPT Code 77049 X2). 
 
You asked the Plan to pre-approve the MRI. You say that the MRIs are necessary. The Plan denied your 
request. The Plan says the MRIs are not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they 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 physician reviewer found 
Breast MRI studies are to be used very selectively. The modality should be restricted to: cases where diagnosis 
is inconclusive, even after standard work-up; evaluation of the post-operative patient when scar tissue cannot 
be differentiated from tumors; patients with positive axillary nodes but no known primary; patients with rupture 
of a breast implant; or determination of the extent of disease in patients with known malignancy, prior to 
treatment (to assure confinement to one segment of the breast). Review of the submitted documentation does 
not support these guidelines have been met. Without the support of the documentation, medical necessity 
cannot be determined. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI, breast, without and with contrast material(s), including (CAD real-time lesion detection, 
characterization and pharmacokinetic analysis), when performed; bilateral (CPT Code 77049 X2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower limb prosthesis and related accessories to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the lower limb prosthesis and related accessories. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items can be 
provided by 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 
the lower limb prosthesis and related accessories to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two pontics and two retainer crowns. 
 
You asked the Plan to pre-approve the retainer crowns and pontics. You say that the enrollee's crowns fell out, 
and you were told that the root was too short, and sometimes this happens. You also say that you would like the 
issue to be fixed, and would like the enrollee to receive a bridge. The Plan denied your request. The Plan says 
pontics are not a covered benefit. The Plan also says that the enrollee has reached the maximum benefit for 
crowns. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, pontics are not among those covered 
under this benefit. The contract says that crowns are limited to two per year. The record shows that the enrollee 
received two crowns on March 5, 2020, and the enrollee's crowns benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pre-approve two pontics and two retainer crowns.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a commode. 
 
You asked the Plan to pre-approve the commode. You say that you would like reconsideration because you are 
not able to get to the toilet at night. The Plan denied your request. The Plan says the records do not indicate that 
you meet coverage criteria for the commode. 
 
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are 
confined to a bed or room. 
 
The file does not show that you are confined to a bed or room as defined by Medicare rules. Therefore, we 
decided that the Plan does not have to pre-approve a commode.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) of the whole body (78816). 
 
You asked the Plan to pre-approve the PET scan with CT scan. You say that the medical records provided 
support the necessity of the requested service in dispute. The Plan denied your request. The Plan says the 
enrollee does not meet the Medicare criteria for the requested service. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they 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 PET scan with CT scan. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee appears to not have a condition for which PET scan would be 
approved. She has no new complaints and fatigue has improved. This test appears to be for routine follow-up 
and there were no plans for treatment. CT of the entire body is not warranted in this setting of the enrollee's 
undergoing regular surveillance following remission from her lymphoma. More focused basic imaging would 
be more appropriate in this setting. Therefore, this request for CT will be considered not medically necessary as 
requested. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PET scan with CT scan have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) of the whole body (78816).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
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 genicular nerve radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has osteoarthritis of the knee. The enrollee 
had a diagnostic genicular nerve block which gave him 50% pain relief. The requested service is considered an 
experimental/ investigational procedure which is the subject of on-going clinical trials. The enrollee is not 
enrolled in a clinical trial. Therefore, the enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation.