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

We decided that the Plan has to pre-approve Lynch Syndrome genetic testing.
You asked the Plan to pre-approve Lynch Syndrome genetic testing. You say that the requested Lynch Syndrome genetic testing is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested Lynch Syndrome genetic testing.
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 Lynch Syndrome genetic testing. Our reviewer says that the requested Lynch Syndrome genetic testing is medically necessary. Our physician reviewer found this enrollee has a family history of Lynch syndrome in a sister with MSH2. Breast cancer may be associated with MSH2. However, even without a personal history of cancer related to Lynch Syndrome this enrollee has a first degree relative with Lynch Syndrome and per the NCCN Guidelines, the enrollee meets criteria for testing. The service is reasonable and 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 Lynch Syndrome genetic testing have been met. Therefore, we decided that the Plan has to pre-approve Lynch Syndrome genetic testing.
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 pre-approve treatment of root canal obstruction, endodontic therapy 
and therapeutic parenteral drug. 
 
You asked the Plan to pre-approve treatment of root canal obstruction, endodontic therapy and therapeutic 
parenteral drug. You say that you need this treatment to continue with chemotherapy. You say that this should 
be covered under medical. The Plan denied your request. The Plan says the services 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, you also have a maximum benefit of 
$1,000 a year for dental services. The records show that with the previous approval of a root canal, you have 
met your maximum benefit for the year. Therefore, we decided that the Plan does not have to pre-approve 
treatment of root canal obstruction, endodontic therapy and therapeutic parenteral drug.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a post and core in addition to crown (D2952).
You asked the Plan to pre-approve the post and core. The Plan denied your request. The Plan says this 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 post and core in addition to crown (D2952).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional aquatic therapy services. 
 
You asked the Plan to pre-approve additional aquatic therapy services. 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. 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 additional aquatic therapy 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 excruciating knee pain. You have received 
11 visits of aquatic therapy services. The documentation shows a 30% improvement since starting therapy, and 
notes improvement in ability to ambulate more upright, ability to stand longer, and increased strength. While 
aquatic therapy is generally accepted as specific and effective therapy for your condition initially, it is not after 
11 visits. The documentation does not support that the requested services are required to be provided by a 
qualified therapist. Therefore, you do 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 additional aquatic therapy services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve additional aquatic therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two core buildups, including any pins when required 
(D2950 x2). 
 
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service 
is not listed as 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 two 
core buildups, including any pins when required (D2950 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right sacroiliac joint injection. 
 
You asked the Plan to pre-approve a right sacroiliac joint injection. 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 a right sacroiliac joint injection. 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 chronic pain syndrome, low back pain, lumbar 
radiculopathy, neuropathy, postlaminectomy syndrome, spinal stenosis, lumbar fusion, morbid obesity, and 
right sacroiliac (SI) joint dysfunction. The documentation documents ?Patient bilateral circumferential hip 
pain. No improvement with SI joint injections". Neurological exam documented decreased sensation on both 
the right and left lower extremities. The documentation does not support that the enrollee meets 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 right sacroiliac joint injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a right sacroiliac joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on January 22, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 
Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented.   
 
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 
physician?s services. 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 physician's services provided on January 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that a buildup and full coverage restoration are 
necessary to restore the tooth to optimum strength and function. You also say that the buildup is needed for the 
retention of the crown. The Plan denied your request. The Plan says this service is 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 a 
core buildup, including any pins when required (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve a power mobility device. You say that you need a power mobility device to move around outside. The Plan denied your request. The Plan says you can safely walk and your home cannot accommodate a power mobility device.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, your condition can be improved by a walker and you cannot safely operate a power mobility device in your home. This means that Medicare rules for coverage of a PMD have not been met. The item at issue in this appeal is being requested for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan cover PMDs for use only outside the home. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a high frequency chest wall oscillation device. 
 
You asked the Plan to provide a high frequency chest wall oscillation device. You say that the enrollee needs a 
high frequency chest wall oscillation device. The Plan denied your request. The Plan says no documentation 
has been submitted to confirm the enrollee suffers from any one of the three diagnostic categories. 
 
The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are 
covered only for patients with cystic fibrosis, bronchietasis, or certain neuromuscular diseases. 
 
The record does not show that the enrollee has cystic fibrosis, bronchiectasis, or a covered neuromuscular 
disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall 
oscillation device can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to 
provide a high frequency chest wall oscillation device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need a shower chair due to your medical 
history. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
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 acupuncture services. Our reviewer 
says that the requested acupuncture services are not medically reasonable and necessary. Our physician 
reviewer found that the enrollee is an 88-year-old female who reported low back pain on July 14, 2020 via a 
telehealth visit. Physical therapy and acupuncture both were planned and ordered. Medicare covers acupuncture 
for low back pain for up to 12 visits over 90 days if it has lasted for over 12 weeks, nonspecific or related to a 
specific treatable condition. The provided documentation does not show that physical therapy had been tried 
and failed or that the low back pain has persisted for 12 weeks or longer. Therefore, without justification made 
for this request at this time, the acupuncture will be considered 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 acupuncture services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve acupuncture services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the alveoloplasty (D7310) for the upper right quadrant.
You asked the Plan to pre-approve the alveoloplasty for the upper right quadrant. You say that the enrollee is
having pain and needs dental treatment. You say that the claim should be processed. The Plan denied your
request. The Plan says the criteria for coverage has not been met.
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. The Plan covers the
alveoloplasty for the upper right quadrant when the services are medically necessary and reasonable.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the alveoloplasty for the upper right
quadrant. Our physician reviewer says the criteria requires the procedure be performed in conjunction with
extractions. Our reviewer found that the documentation does not indicate the presence of four teeth to be
extruded in the quadrant so the criteria for coverage has not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the alveoloplasty for the upper right quadrant have not been met. Therefore, we
decided that the Plan does not have to pre-approve the alveoloplasty (D7310) for the upper right quadrant.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synthroid Tab.
You asked the Plan to pre-approve Synthroid Tab. You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Part B Medicare benefit.
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 Synthroid Tab.
Benefits for Synthroid 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection, expandable controller, and 
harness for the enrollee. 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is able to control the power options with their own switches. 
 
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 accessories. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found none of these items are needed for optimal power mobility aid functioning. As such, they are 
convenience items, and 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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection, expandable controller, and harness for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient laboratory services provided on January 15, 2020. 
 
You asked the Plan to pay for the outpatient laboratory services. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 outpatient laboratory services provided on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. The Plan denied your request. The Plan says this item is not 
a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitoring system. 
 
You asked the Plan to pre-approve a continuous glucose monitoring system. You say that the enrollee needs a 
continuous glucose monitoring system. The Plan denied your request. The Plan says criteria is not met for a 
continuous glucose monitoring system. 
 
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 a continuous glucose monitoring 
system. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found although the provided records show that the enrollee meets most of the 
criteria, the prescriptions and notes suggest the enrollee is only testing glucose up to three times daily, whereas 
four or more times daily is required in order to meet criteria. Therefore, the enrollee does not meet the 
requirement for a continuous glucose monitoring system. 
 
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 continuous glucose monitoring system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitoring system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950). 
 
You asked the Plan to pre-approve the core buildup (D2950). You say that you need to remove the current 
buildup to remove the reoccurring decay. You say that it is medically necessary to complete this treatment. The 
Plan denied your request. The Plan says the 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 the 
core buildup (D2950).