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

We decided that the Plan does not have to pre-approve the CT scan, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT Code 75571), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the CT scan is necessary. The Plan denied your request. The Plan says the CT scan is not 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 physician reviewer found despite some potential benefit in screening, this patient does not have any symptoms. This test is not appropriate for screening purposes in this patient without symptoms. 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 not been met. Furthermore, the rules say that screening tests are excluded from coverage. Therefore, we decided that the Plan does not have to pre-approve the CT scan, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT Code 75571), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower partial denture (D5214). 
 
You asked the Plan to pre-approve the partial denture. You say that you were in a car accident and has not been 
able to wear the current lower partial denture after the accident. The Plan denied your request. The Plan says 
this service is not covered under the plan 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. The health plan contract 
specifically lists partial dentures as excluded from coverage. 
 
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 
lower partial denture (D5214).
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 are appealing. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-invasive oximeter device (E0445).
You asked the Plan to pre-approve the non-invasive oximeter device. You say that you suffer from asthma among other conditions and with this device you can measure oxygen in your blood. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-invasive oximeter device have not been met. Therefore, we decided that the Plan does not have to pre-approve the non-invasive oximeter device (E0445).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight manual wheelchair and attachments. 
 
You asked the Plan to pre-approve these services. You say that you need this wheelchair to access medical care 
and essential services in the community. The Plan denied your request. The Plan says that this is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a lightweight manual wheelchair and attachments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services for a second opinion.
You asked the Plan to pre-approve physician's services for a second opinion. You say that you and the enrollee have lost confidence in the Plan's ability to provide quality care and treatment. The Plan denied your request. The Plan says there is no medical indication for referral out of plan.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services for a second opinion.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy visits. 
 
You asked the Plan to pre-approve 10 additional physical therapy visits. The Plan denied your request. The 
Plan says the request is 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 10 additional physical therapy visits. 
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 there is no indication residual deficits 
could not be addressed through a home 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 10 additional physical therapy visits. have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete denture - maxillary (D5110) and complete 
denture - mandibular (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says the services are not a covered benefit under the plan. 
 
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. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve complete 
denture - maxillary (D5110) and complete denture - mandibular (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion orthotic device. 
 
You asked the Plan to pre-approve MyoPro Motion device. You say that this is medically necessary. The Plan 
denied your request. The Plan says the denial of authorization for this item is correct, because this device is 
excluded from coverage by the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve MyoPro Motion device. Our reviewer 
says that the enrollee does not meet the Medicare criteria for the requested orthotic device. Our physician 
reviewer found this device is not medically reasonable or necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro Motion orthotic device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids (V5261). 
 
You asked the Plan to pre-approve the hearing aids. You say that you would like reconsideration because you 
were told hearing aids were a covered benefit. The Plan denied your request. The Plan says the recommended 
hearing aids are not a covered benefit according to Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though the hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these 
types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids 
(V5261).  
 
Your complaint about receiving incorrect information from the Plan is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns, core buildup, periodontal scaling and root 
planing, localized delivery of antimicrobial agents and gingival irrigation. 
 
You asked the Plan to pre-approve the crowns, core buildup, periodontal scaling and root planing, localized 
delivery of antimicrobial agents and gingival irrigation. You say that you need this work for your upper right 
teeth. You say that you can't call on Medicaid to help. 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, core buildup, periodontal scaling and root planing, localized delivery of antimicrobial agents and 
gingival irrigation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Clean cut shower/tub, a Zero Entrance shower, and a 
wheelchair ramp. 
 
You asked the Plan to pre-approve a Clean cut shower/tub, a Zero Entrance shower, and a wheelchair ramp. 
You say that you have had rheumatoid arthritis since 1993 and there is no cartilage in your knees or ankles. 
You say that you are not ab le to get into the bath tub, even with help. You say that you have 7 steps to get in 
and out of your house. You say that, with your limited mobility, doctor visits are nearly impossible. You say 
that your doctor agrees that you need the requested items and has submitted a letter to support their necessity. 
The Plan denied your request. The Plan says the items in dispute are non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal does not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Clean cut shower/tub, a Zero Entrance shower, and a 
wheelchair ramp.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint. 
 
You asked the Plan to pre-approve repeat radiofrequency ablation (64635). You say that the enrollee needs the 
procedure for pain relief. The Plan denied your request. The Plan says the request is 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 looked at the file and Medicare rules. The record does not show improvement of pain for at least 6 months. 
Based on this information, we decided that Medicare rules for coverage of repeat radiofrequency ablation 
(64635) have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by 
neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or 
sacral, single facet joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lower dentures (D5110). 
 
You asked the Plan to pre-approve lower dentures. You say that your current dentures do not fit properly. The 
Plan denied your request. The Plan says this exceeds the frequency limitation for dentures. 
 
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, dentures are covered only once every 
five years. The record shows that you received a set of dentures covered by the Plan in August 2019. Therefore, 
we decided that the Plan does not have to pre-approve lower dentures (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (21249). 
 
You asked the Plan to pre-approve the implant. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this service is not covered under your benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve an endosteal implant 
(21249).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous decompression laminotomy (0275T). 
 
You asked the Plan to pre-approve percutaneous decompression laminotomy. You say that based on your 
review, detailed above and the treatment algorithm for LSS, you believe the enrollee is an excellent candidate 
for this therapy. The Plan denied your request. The Plan says the Medicare criteria has not been met as there is 
no documentation submitted that indicates any details of an approved clinical study. 
 
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 percutaneous decompression 
laminotomy. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the medical records provided  do not meet the 
requirements listed in the  National Coverage Determination (NCD) for Percutaneous Image-Guided Lumbar 
Decompression for Lumbar Spinal Stenosis (150.13) as the records do not indicate that the patient is enrolled in 
an approved clinical study. 
 
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 decompression laminotomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve percutaneous decompression laminotomy (0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lysol wipes and sanitizer. 
 
You asked the Plan to pre-approve Lysol wipes and sanitizer. The Plan denied your request. The Plan says that 
these items do not treat a medical condition and are convenience items. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve Lysol wipes and sanitizer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prosthetic eye. 
 
You asked the Plan to pre-approve the prosthetic eye. You say that the ocular prosthesis is medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that information must be submitted by the supplier or 
provider to corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. The case file does not show that any medical records or office notes 
were submitted to confirm that Medicare coverage criteria have been met. Without this necessary information, 
the medical necessity of the requested item cannot be substantiated. Based on this information, we decided that 
Medicare rules for coverage of the prosthetic eye have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a prosthetic eye.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the removal of torus mandibularis (D7473). You say that you have new 
dentures you can't wear because of the bone sticking out. You say that you can't eat regular foot and your gum 
is hurting all the time. 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 
removal of torus mandibularis (D7473).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair cup holder. 
 
You asked the Plan to pre-approve a power wheelchair cup holder. You say that the enrollee needs a Group 3 
power wheelchair and cup holder. The Plan denied your request. The Plan says a cup holder does not serve a 
medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power wheelchair cup holder.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant (D6010), 
prefabricated abutment (D6056) and implant supported crown (D6065). 
 
You asked the Plan to pre-approve the surgical placement of implant (D6010), prefabricated abutment (D6056) 
and implant supported crown (D6065). You say that the service is required not cosmetic or elective. You say 
that it is unfair for insurance to cover no part of this. 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 
surgical placement of implant (D6010), prefabricated abutment (D6056) and implant supported crown 
(D6065).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a physical therapy evaluation (97162) and therapeutic 
exercises (97110) to be rendered by an out of network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
these services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a physical 
therapy evaluation (97162) and therapeutic exercises (97110) to be rendered by an out of network (OON) 
provider.