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

 
We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device (22869). 
 
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction 
device. You say that this is medically necessary. The Plan denied your request. The Plan says this is 
experimental. 
 
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 insertion of interlaminar/interspinous 
process stabilization/distraction device. Our reviewer says that the requested services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the requested device is 
experimental. More research is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device 
have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of 
interlaminar/interspinous process stabilization/distraction device (22869).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung 
Cancer Screening (G0297). 
 
You asked the Plan to pre-approve the lung cancer screening. You say that the lung cancer screening is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for this test to be covered, you must have a 
tobacco smoking history of at least 30 pack-years (one pack-year = smoking one pack per day for one year; 1 
pack = 20 cigarettes).  
 
 
 
 
 
 
 
 
 
 
 
We looked at the file and Medicare rules. The record shows you smoke 5 or less cigarettes a day. The record 
does not include a written order that meets Medicare requirements. Based on this information, we decided that 
Medicare rules for coverage of the lung cancer screening have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Low Dose Computed Tomography (LDCT) Lung Cancer Screening 
(G0297).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation services. 
 
You asked the Plan to pre-approve additional routine transportation services. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says additional transportation trips are 
not a covered 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 50 one-way 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 routine transportation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor sensors 
(K0553). 
 
You asked the Plan to pre-approve Freestyle Libre continuous glucose monitor sensors. You say that the 
enrollee needs this to have the best possible care. 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 CGMs and related supplies are covered when the 
beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered 
continuous subcutaneous insulin infusion (CSII) pump. 
We looked at the file and Medicare rules. The records do not show the beneficiary is insulin-treated with 
multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin 
infusion (CSII) pump. Based on this information, we decided that Medicare rules for coverage of Freestyle 
Libre continuous glucose monitor sensors have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Freestyle Libre continuous glucose monitor sensors (K0553).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve use of a home ventilator. 
 
You asked the Plan to pre-approve ventilator. You say that a BiPAP was not efficient enough to keep the 
enrollee out of the hospital, and her compliant use of the Trilogy ventilator will reduce hospital admissions. 
The Plan denied your request. The Plan says that the denial of authorization for this device is correct, because 
the records do not show that the enrollee has failed BiPAP. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve ventilator. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested ventilator. Our physician reviewer found the enrollee's 
medical history includes that she is a chronic smoker, requires home oxygen, and has failed BiPAP. It was 
reported that the enrollee tried BiPAP at home but required readmission to the hospital with its use. The 
Trilogy ventilator device has already been approved and used at home for at least 2 months, preventing 
admission to the hospital. It appears that in this situation when lung function may only worsen and with failure 
of BiPAP as well as clear success with the Trilogy device, the enrollee meets Medicare criteria for the 
requested mechanical ventilation device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ventilator have been met. Therefore, we decided that the Plan has to pre-
approve use of a home ventilator.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar laminectomy/discectomy (0275T). 
 
You asked the Plan to pre-approve the back surgery. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the record does not include documentation to 
support the member consented to the clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that the study must provide and obtain meaningful 
informed consent from patients regarding the risks associated with the study items and/or services, and the use 
and eventual disposition of the collected data. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the back surgery have not been met. Specifically, the record does not include any documentation 
showing that the member has consented to the clinical trial. Therefore, we decided that the Plan does not have 
to pre-approve the lumbar laminectomy/discectomy (0275T).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI (Magnetic Resonance Imaging). 
 
You asked the Plan to pre-approve MRI. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the documentation does not support that the requested services are 
medically reasonable or necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We looked at the file and Medicare rules. Review of the file shows that no medical records or documentation 
was provided to support that the requested MRI is medically reasonable or necessary. Based on this 
information, we decided that Medicare rules for coverage of MRI have not been met. Therefore, we decided 
that the Plan does not have to pre-approve MRI (Magnetic Resonance Imaging).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation, 2 root canals, and 2 crown to be 
provided by an endodontist. 
 
You asked the Plan to pre-approve the dental services. You say that you have 2 broken teeth. You say that the 
dentist advised you may need root canals. You say that your dentist referred you to an endodontist for the root 
canals and crowns. The Plan denied your request. The Plan says dental services provided by an endodontist 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. Additionally, dental services provided by an endodontist are not 
covered. Therefore, we decided that the Plan does not have to pre-approve a consultation, 2 root canals, and 2 
crown to be provided by an endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture and a complete maxillary 
denture. 
 
You asked the Plan to pre-approve the mandibular partial denture and complete maxillary denture. You say that 
you need these dentures, and need help paying for them. The Plan denied your request. The Plan says these 
services are not covered under your benefit 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. Therefore, we decided that the Plan does not have to pre-approve a 
mandibular partial denture and a complete maxillary denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554). 
 
You asked the Plan to pre-approve the CGM. You say that the CGM is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that in order for a CGM to be covered, the enrollee 
must be insulin-treated with multiple (three or more) daily injections of insulin.  
 
We looked at the file and Medicare rules. The record shows you take oral medications for your diabetes and do 
not inject insulin multiple times daily. Based on this information, we decided that Medicare rules for coverage 
of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) (K0554).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the thorax (71250). 
 
You asked the Plan to pre-approve a CT scan of the thorax. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the records do not indicate why the previous scan was not sufficient. 
 
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 a CT scan of the thorax. Our reviewer 
says that the requested scan is medically necessary. Our physician reviewer found the enrollee has severe 
chronic obstructive pulmonary disease and changing imaging abnormalities.  The most recent followup CT of 
the chest showed a new ground glass infiltrate in the right upper lobe. This lesion was not present on the 
previous scans.  It is considered reasonable and medically necessary to re-image the chest at this time to assure 
resolution of this abnormality. 
 
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 CT scan of the thorax have been met. Therefore, we decided that the Plan has 
to pre-approve a computed tomography (CT) scan of the thorax (71250).  
 
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 endodontic therapy of an anterior tooth (D3310), 
endodontic therapy of a molar tooth (D3330), and two prefabricated posts and cores in addition to crowns 
(D2954 x2). 
 
You asked the Plan to pre-approve endodontic therapies and prefabricated posts and cores. You say that the 
enrollee has significant breakdown on tooth #'s 3 and 8. You also say that the enrollee is experiencing pain 
upon biting, with multiple fractures. The Plan denied your request. The Plan says these 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, 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 
endodontic therapy of an anterior tooth (D3310), endodontic therapy of a molar tooth (D3330), and two 
prefabricated posts and cores in addition to crowns (D2954 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter tricuspid valve repair (Tricuspid Clip). 
 
You asked the Plan to pre-approve the services. You say that the service is necessary. The Plan denied your 
request. The Plan says there is not enough medical proof that shows the safety and/or success of this procedure. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found devices for transcatheter tricuspid valve repair are considered investigational in the United 
States (US). 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcatheter tricuspid valve repair (Tricuspid Clip).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) coronary calcification 
testing. 
 
You asked the Plan to pre-approve CT coronary calcium test. You say that your doctor wants to be sure that 
your cholesterol is not causing calcification. The Plan denied your request. The Plan says the denial of 
authorization for this service is correct, because this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring (such as CT 
coronary calcification) is not a covered service.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CT coronary calcium test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve computed tomography (CT) coronary calcification testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath/shower chair with wheels. 
 
You asked the Plan to pre-approve a shower chair. You say that you are unable to stand alone. The Plan denied 
your request. The Plan says the requested 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 bath/shower chair with wheels.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says there 
are in-network providers who can provide the 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 the 
requested physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950), pontic (D6240), implant 
supported crown (D6066), crown (D6750), repair implant abutment (D6095) and partial denture sectioning 
(D9120). 
 
You asked the Plan to pre-approve core buildup (D2950), pontic (D6240), implant supported crown (D6066), 
crown (D6750), repair implant abutment (D6095) and partial denture sectioning (D9120). You say that due to 
having pain and headaches, the enrollee would benefit from the suggested treatment. 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 core 
buildup (D2950), pontic (D6240), implant supported crown (D6066), crown (D6750), repair implant abutment 
(D6095) and partial denture sectioning (D9120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a temporary lower denture (D5821), core build up 
(D2950 x 2), and a ready-made post for filling for a crown (D2954). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered by your 
plan. The Plan denied your request. The Plan says temporary dentures are not listed as a covered service. The 
Plan says core build up is not listed as a covered service. The Plan also says ready-made post for filling for a 
crown 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 a 
temporary lower denture (D5821), core build up (D2950 x 2), and a ready-made post for filling for a crown 
(D2954).
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 the only way for you to get to the bathroom is 
a shower chair with wheels. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fetal chromosomal micro-deletion analysis and unlisted 
molecular pathology procedure. 
 
You asked the Plan to pre-approve fetal chromosomal micro-deletion analysis and unlisted molecular pathology 
procedure. 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 a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The fetal chromosomal micro-deletion analysis and unlisted molecular pathology procedure at issue in this 
appeal, is being requested solely for screening purposes. Medicare does not cover this test solely for screening 
purposes. Therefore, we decided that the Plan does not have to pre-approve fetal chromosomal micro-deletion 
analysis and unlisted molecular pathology procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete endosteal implant replacement. 
 
You asked the Plan to pre-approve the implant replacement. You say that you would like reconsideration 
because the member's condition is no longer in the dental wheelhouse. The Plan denied your request. The Plan 
says this is not a Medicare covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 
complete endosteal implant replacement.