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

 
We decided that the Plan does not have to pay for the full mouth debridement provided on November 4, 2020. 
 
You asked the Plan to pay for the full mouth debridement. You say that you would like this service to be 
covered. 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 pay for the full 
mouth debridement provided on November 4, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) scan of the face. 
 
You asked the Plan to pre-approve an MRI scan. 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 MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an MRI scan. Our reviewer says that 
the documentation does not support that the requested MRI scan is medically reasonable or necessary. Our 
physician reviewer found the enrollee has headaches and visual disturbances. The enrollee been approved for 
MRI/MRA of the brain, orbits and neck. The documentation provided indicates that the physician intended to 
obtain these tests. The documentation does not indicate that an MRI of the face was needed. The requested test 
is not medically necessary or reasonable to diagnose or treatment the enrollee's condition. Therefore, the 
enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a magnetic resonance imaging (MRI) scan of the face.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient stay provided from August 6, 
2020, through August 9, 2020. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that you were only supposed to stay 
overnight. You say that you were charged another copayment, but a $90 copayment should take care of the bill. 
The Plan denied your request. The Plan says the copayment applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $260 
copayment per day, days 1 to 5, at an in-network inpatient hospital. 
 
You have been asked to pay a $780 copayment for the inpatient stay. ($260/day x 3 days = $780). The inpatient 
stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the inpatient stay provided from August 6, 2020, through August 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular screening test provided on June 11, 2020. 
 
You asked the Plan to pay for the cardiovascular screening. You say that you would like reconsideration 
because this testing is medically necessary. The Plan denied your request. The Plan says Medicare denies 
coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomaticpatients 
with suspected or documented cardiovascular disease. 
 
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 test at issue in this appeal, the cardiovascular screening, was 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 pay for the cardiovascular screening test provided on June 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer. 
 
You asked the Plan to pre-approve the Superion procedure. You say that this treatment is the best option for the 
patient. The Plan denied your request. The Plan says this procedure is not currently supported by literature for 
this enrollee. 
 
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 Superion procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this enrollee has multiple degrees of spinal stenosis, many not at FDA indicated 
levels of "moderate" spinal stenosis. FDA contraindications include spinal instability, scoliosis, obesity, and 
osteoporosis, and have not been adequately addressed in the medical records. Detailed documentation is not 
evident regarding discussion of scoliosis of the lumbar spine with no documentation of the Cobb angle. There 
is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this 
patient. Therefore, the request for Superion Vertiflex device is not medically reasonable or 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 Superion procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve implantation of a cochlear device, for the enrollee. 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says that the Medicare rules have not been met. 
 
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 physician reviewer 
found Cochlear implantation may be covered for treatment of bilateral pre- or-post-linguistic, sensorineural, 
moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification. Limited 
benefit from amplification is defined by test scores of less than or equal to 40% correct in the best-aided 
listening condition on tape-recorded tests of open-set sentence cognition. The enrollee meets the CMS criteria 
based on their audio testing results. The enrollee's testing was below the 40% threshold level under aided 
conditions. Even though SNN is not mentioned in the NCD criteria does not mean the enrollee is not eligible 
for a cochlear implant. SNR equals how loud the sentences needed to be turned up above the noise floor so that 
the enrollee could repeat them correctly 50% of the time. At SNR 5dB, the enrollee only got 7% of the words / 
sentences correct. This is under aided conditions. Our physician reviewer believes the enrollee has met CMS 
criteria for a cochlear implant. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve implantation of a cochlear device, for the enrollee.  
 
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 a fixed bridge for teeth # 5, 6, 7, 8, 9, 10, 11, 12, and 13. 
 
You asked the Plan to pre-approve the fixed bridge. You say that you do not have any teeth available to grab. 
You say that you have terrible pain. You say that you have an appointment to receive this bridge for May 19, 
2021. The Plan denied your request. The Plan says fixed prosthetics 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, a fixed bridge is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a fixed bridge for 
teeth # 5, 6, 7, 8, 9, 10, 11, 12, and 13.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve the requested item. You say that you need the monitor to control high blood 
pressure. The Plan denied your request. The Plan says the item is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

You asked the Plan to pay for the comprehensive oral evaluation. You say that your previous dentist retired, 
and this service was necessary. The Plan denied your request. The Plan says this service exceeds the frequency 
limitation in 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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on January 10, 2019 and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) provided on October 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the hearing aids purchased on January 16, 2020.
You asked the Plan to provide reimbursement for the hearing aids. You say that you were told that this needed to be paid up front but that you would be reimbursed by your plan, but the reimbursement was denied. The Plan denied your request. The Plan says you did not contact the plan's hearing vendor to obtain these hearing aids. As such, this purchase is not covered by the Plan.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are provided through the Plan's hearing vendor. There is no evidence that you were directed to this provider by the plan or a plan provider. You chose an out of network provider for the hearing aids without contacting your plan's hearing vendor as required by contract. Therefore, we decided that the Plan does not have to provide reimbursement for the hearing aids purchased on January 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for teeth # 10 and 11. 
 
You asked the Plan to pre-approve the dental services. You say that the core build up is necessary for the 
enrollee. The Plan denied your request. The Plan says core build up 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, core build up is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up 
(D2950) for teeth # 10 and 11.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve amitiza capsules. 
 
You asked the Plan to pre-approve self-administered drug. You say that this medication is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
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 amitiza capsules.  
 
Benefits for self-administered drug 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 additional skilled nursing facility (SNF) coverage after 
April 10, 2021. 
 
You asked the Plan to pre-approve additional SNF coverage. 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 must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from October 12, 2020. The 
Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve additional skilled nursing facility (SNF) coverage after April 10, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that continued inpatient skilled nursing 
facility care is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for 
coverage of continued SNF care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 continued SNF care. Our reviewer says 
that continued inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found 
that at the time of the admission, you required skilled rehabilitation services to improve function due to 
weakness and deconditioning. You did not have skilled nursing needs. As of April 8, 2021, you did not require 
any skilled nursing or rehabilitation services on a daily basis. You were not expected to make measurable gains 
within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with 
mobility or activities of daily living. You did not require skilled therapy to establish a safe and effective 
maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a 
SNF level of care. You did not have any parental medications, complex wound care or nutrition given via a 
feeding tube. You received skilled care and improved; however, your function had plateaued and you did not 
require any further inpatient skilled rehabilitation services.   

Your function was at or near your prior level of function and you could be discharged to a lower level of care 
for further services. As of April 8, 2021, you required custodial 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued inpatient skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for 
tracheostomy supplies. 
 
You asked the Plan to pre-approve the referral. You say that this should be approved. The Plan denied your 
request. The Plan says an in-network provider is available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a referral to an out-of-network provider for tracheostomy supplies.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CT scan of the thorax for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee had prior 
T1bN0M0 squamous cell cancer who was treated with primary radiation therapy in 2016 who now has 
T4N0M0 recurrent laryngeal squamous cell carcinoma and underwent total laryngectomy, bilateral neck 
dissection, anterolateral thigh free flap and tracheoesophageal prosthesis in June 2018. The request is for a CT 
scan of the thorax. In this case, the enrollee underwent a CT scan of the chest in February 2020. It 
demonstrated interval development of centrilobular nodules and groundglass opacities consistent with chronic 
aspiration. The enrollee was seen in November 2020 and underwent negative laryngoscopy. The documentation 
does not document an indication for a repeat chest CT.  The medical reasonableness and necessity of the 
requested test has not been demonstrated. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the thorax for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that you are willing to try this option to treat your pain 
and discomfort. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because Vertiflex has not been shown to be safe and effective in long-term studies. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective and is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because Vertiflex is 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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex device is experimental. More research is needed to show its 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interspinous spacer device (Vertiflex).