Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of an endosteal implant (D6010), 
a custom fabricated abutment (D6057), and an abutment supported crown (D6058) for tooth # 19. 
 
You asked the Plan to pre-approve the implant services. You say that the services for tooth # 19 should be 
covered. You say that you already had tooth # 19 extracted. You also say that without the implant, your teeth 
will shift. The Plan denied your request. The Plan says coverage for implant services is limited to anterior teeth. 
The Plan says that tooth # 19 is a posterior tooth. The Plan also says that the implant services requested for 
tooth # 19 are not covered. 
 
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 
surgical placement of an endosteal implant (D6010), a custom fabricated abutment (D6057), and an abutment 
supported crown (D6058) for tooth # 19.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that it is felt that IRF care is medically necessary. The 
Plan denied your request. The Plan says the enrollee has no acute medical issues and is not likely to tolerate 
three hours of daily therapy. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee was admitted to the hospital on 12/09/2020 with COVID-19 infection, 
pneumonia and respiratory failure. He was treated in the hospital with intravenous antibiotics, respiratory 
treatments, corticosteroids, diuretics, enoxaparin and high flow oxygen. He is weak and deconditioned and is 
working with physical and occupational therapy. He is walking up to 30 feet with a rolling walker with contact 
guard assistance and is minimum to moderate assist for transfers and maximum assist for some activities of 
daily living. His endurance is reported to be poor and he is reported to be groggy with delayed responses.  
 
Based on the medical records provided, the complexity of the patient's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The patient does require physical therapy and occupational therapy services, but the patient does not require an 
 
 
intensive inpatient rehabilitation therapy program. There is also concern that the patient will not be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient 
rehabilitation facility due to poor endurance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve relaxation gas (D9230), the surgical placement of 
endosteal implants (D6010 x 10) and prefabricated abutments (D6056 x 10). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has a history of oral and base 
of tongue cancer. You say that it was treated with surgical resection and radiation therapy. You say that the 
enrollee does not have the anatomy that is necessary to have traditional dentures. You also say that without the 
enrollee's dentition restored, he will have prolonged difficulties with nutrition, speech, and quality of life. The 
Plan denied your request. The Plan says relaxation gas is not listed as a covered service. The Plan says that the 
implant placement is not listed as a covered service. The Plan also says that prefabricated abutments are not 
listed as covered services. 
 
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 
relaxation gas (D9230), the surgical placement of endosteal implants (D6010 x 10) and prefabricated abutments 
(D6056 x 10).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Latuda Tab. 
 
You asked the Plan to pre-approve Latuda Tab. You say that the enrollee has been stable on this medication. 
The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Latuda Tab.  
 
Benefits for Latuda Tab may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve the SNF services. You say that you cannot do anything for yourself and you 
are not taking the feeding tube and as a result, you risk aspirating. You say that you do not have the means to 
have someone to care for you and your quality of life would be adversely affected if not admitted to a SNF. 
The Plan denied your request. The Plan says based on Medicare guidelines, the SNF services you and/or your 
provider are requesting do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above 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 the SNF services. Our reviewer says 
that daily skilled services are not medically necessary. Our physician reviewer found that you have stabilized 
medically and you are ready for discharge from the hospital. You do not require skilled nursing and/or skilled 
therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a 
lower level of care. Although further rehabilitation services would be appropriate to improve function, as a 
practical matter, the daily skilled services can be provided at a lower level of care rather than a skilled nursing 
 
 
facility. You do not have any parental medication or complex wound care. You have a feeding tube at this time 
but it is unclear if you are accepting nutrition via the tube. You can have intermittent skilled nursing care at a 
lower level for the feeding tube. You are medically stable without any acute exacerbations of chronic medical 
problems. Your physical function is at or near your baseline and you can receive services at a lower level of 
care. Admission to a SNF for inpatient skilled rehabilitation services is not medically 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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on August 12, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you thought authorization was taken care of 
and that you cannot afford this bill. The Plan denied your request. The Plan says neither you nor your family 
doctor requested authorization to see this out-of-network doctor.  Unauthorized, non-plan 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 in this case is not a network provider with the Plan. 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 the medical services provided on August 12, 2020 by an out of 
network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the seat lift mechanism of a seat lift chair. 
 
You asked the Plan to pre-approve the seat lift mechanism of a seat lift chair. You say that your current recliner 
is worn out and you use the recliner to nap. The Plan denied your request. The Plan says you are able to climb 
in and out of your current rocking recliner. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed above are met. Medicare does not cover the upholstered portion of a seat lift chair. 
 
We looked at the file and Medicare rules. Your evaluation shows you are able to rise from your current chair. 
Based on this information, we decided that Medicare rules for coverage of the seat lift mechanism of a seat lift 
chair have not been met. Therefore, we decided that the Plan does not have to pre-approve the seat lift 
mechanism of a seat lift chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a standing frame (E0683). 
 
You asked the Plan to pre-approve the standing frame. You say that the standing frame is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that standing frames are not covered by Medicare.  
 
We looked at the file and Medicare rules. The requested item is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the standing frame have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a standing frame (E0683).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve the hearing aids. The Plan denied your request. The Plan says the hearing 
aids are not medically reasonable and necessary. The documents submitted contain no findings other than wax 
was present in the ear canals. 
 
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 hearing aids. Our reviewer says that 
the requested hearing aids are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that, in general, hearing aids could be considered for a patient with bilateral sensorineural 
hearing loss. However, the documentation supporting this diagnosis is severely lacking. There is no 
documented audiogram. The SRT was given for each side, but that is insufficient to determine if a patient 
needs hearing aids. Since there is no audiogram or ear exam, it is unclear if the enrollee has another ear 
condition that could be corrected by surgery instead of hearing aids. Without an audiogram, one cannot 
approve a hearing aid as 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 the hearing aids have not been met. Therefore, we decided that the Plan does 
not have to pre-approve hearing aids.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary for assistance with daily 
living. The Plan denied your request. The Plan says this is considered custodial care and personal care. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found the provided records 
do not document a skilled need. The requested services are custodial in nature. Based on the medical records 
provided, there is no documentation that the home health aide services are reasonable and necessary to the 
treatment of your illness or injury by the skilled professional staff. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve home health aide visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) performed on July 
23, 2020. 
 
You asked the Plan to pay for a determination of refractive state. You say that this procedure was done to 
prepare for surgery and was not routine. The Plan denied your request. The Plan says rules for payment have 
not been met. 
 
Medicare generally does not cover routine vision and eyewear services. Medicare does not cover refractive 
procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury 
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 covers these services as part of a routine eye exam once 
per calendar year. 
 
 
 
 
 
 
 
 
We looked at the file and the Plan's rules. We noted that a determination of refractive state was already 
performed earlier in the calendar year on July 10, 2020. Based on this information, we decided that the Plan's 
rules for coverage of a determination of refractive state have not been met. Therefore, we decided that the Plan 
does not have to pay for a determination of refractive state (92015) performed on July 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Shingrix vaccination . 
 
You asked the Plan to pre-approve Shingrix. You say that the vaccine should be covered. The Plan denied your 
request. The Plan says this vaccine is not eligible for coverage under the Part B medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Shingrix. The Plan 
follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Shingrix. 
Therefore, we decided that the Plan does not have to pre-approve a Shingrix vaccination .  
 
Benefits for Shingrix may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a TENS unit. 
 
You asked the Plan to pre-approve the unit. You say that this is medically necessary. The Plan denied your 
request. The Plan says services that are not medically necessary are not covered under the benefit plan. 
 
The Plan must follow Medicare rules. The rules say that a TENS unit can be only be covered for enrollees in a 
clinical study.  
 
There is no evidence of enrollment in a clinical study. Based on this information, we decided that Medicare 
rules for coverage of the unit have not been met. Therefore, we decided that the Plan does not have to pre-
approve a TENS unit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the occlusal guard (D9945). 
 
You asked the Plan to pre-approve the dental item. You say that you are being treated for oromandibular 
dystonia. You say that your doctor recommended you should get fitted for a mouth piece. You also say that you 
received a denial for the item due to it being dental in nature. The Plan denied your request. The Plan says the 
occlusal guard 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 
occlusal guard (D9945).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantable loop recorder (CPT Code 33285). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 the service. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found based on the records the patient has atrial fibrillation. In this 
circumstance, if evaluation for recurrent atrial fibrillation or atrial fibrillation burden is thought to be medically 
necessary then standard initial evaluation includes Holter monitoring and external prolonged event monitoring 
that is patient activated and/or auto-triggered. There is no documentation that the patient has undergone these 
tests or that the patient would not tolerate wearing these external devices. The records do not support the 
medical necessity for an implantable loop recorder 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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve implantable loop recorder (CPT Code 33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro electronic arm brace. 
 
You asked the Plan to pre-approve the MyoPro brace. You say that the enrollee has not made good progress 
with therapy, and this MyoPro device is the best option to allow her to regain function. The Plan denied your 
request. The Plan says a review of current medical literature shows that these service(s) do not have proven 
benefit and are considered 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 pre-approve the MyoPro brace. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee is a 43-year-old female with a past medical history of a stroke with left-sided 
weakness. A MyoPro electronic arm brace has been requested. Based on the medical records provided, there is 
no documentation that the MyoPro electronic arm brace at issue in this case is medically reasonable and 
necessary. Current guidelines consider robotic therapy of "uncertain utility compared with dose-matched 
conventional upper limb exercise therapies". 
 
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 brace have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a MyoPro electronic arm brace.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional transportation. You say that you need to get medicine at the 
pharmacy. The Plan denied your request. The Plan says after the last trip is utilized, the benefit will be 
exhausted. 
 
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 24 one-way trips per year.  
 
The file shows that at the time of the request, 23 trips had been used. We looked at your request, the records in 
the case file, and the rules. Once 24 trips have been used, you will have exhausted the Plan maximum benefit 
for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pre-fabricated post and core in addition to a crown (D2954). 
 
You asked the Plan to pre-approve the pre-fabricated post and core in addition to a crown. You say that the 
services are medically necessary. The Plan denied your request. The Plan says the requested service is not a 
covered benefit. 
 
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 a 
pre-fabricated post and core in addition to a crown (D2954).