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

We decided that the Plan does not have to pre-approve surgery to repair broken clavicle.

You asked the Plan to pre-approve surgery to repair broken clavicle. 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 surgery to repair broken clavicle. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found that you sustained a right displaced clavicle fracture in 2017. X-rays in
February 2018 showed a distal right clavicle fracture with superior subluxation of the lateral aspect of the
medial fragment as compared with the distal fragment. Clinical reports have not evidenced significant residual
right shoulder pain or dysfunction. There is right clavicular deformity and mild tenderness to palpation
documented. Multiple orthopedic reports have been reviewed and surgery to treat the right clavicular fracture
has not been recommended.

You have requested surgery to address the broken clavicle that is not within the recommended procedures
supported by evidence based medical literature, in this case. There are significant psychiatric issues
documented, as well as current smoking status, that would not support proceeding with surgery due to the high
risk of failure. Therefore, you do not have a diagnosis, condition, and/or symptoms that meet the Medicare
criteria for the requested surgery. The request for surgery would not be considered the standard of care for the
treatment of your condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of surgery to repair broken clavicle have not been met. Therefore, we decided that
the Plan does not have to pre-approve surgery to repair broken clavicle.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a mouth guard. 
 
You asked the Plan to pre-approve the mouth guard. You say that you sleep better when you use both the 
continuous positive airway pressure (CPAP) and the oral appliance. The Plan denied your request. The Plan 
says that Medicare does not cover primary dental services provided for the care and treatment of teeth or 
structures directly supporting teeth, regardless of cause or complexity. The Plan also says that the mouth guard 
is considered primarily dental in nature, and is not considered treatment for sleep apnea. 
 
The Plan follows Medicare rules. Medicare rules say that a custom fabricated mandibular advancement oral 
appliance (E0486) used to treat OSA is covered if the enrollee has had a Medicare-covered sleep test that 
shows sleep apnea with an AHI or RDI is greater than or equal to 15 events per hour with a minimum of 30 
events. 
 
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 mouth guard. Our reviewer says that 
the service is medically necessary. Our physician reviewer found your use of a bruxism occlusal appliance is 
not for the care or treatment of teeth or of the supporting structures of the teeth. Our reviewer found that it is 
for the continued effective treatment of your sleep apnea via use of a CPAP device by controlling bruxism and 
clenching. 
 
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 mouth guard have been met. Therefore, we decided that the Plan has to pre-
approve a mouth guard.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair (K0851). 
 
You asked the Plan to pre-approve a group 3 heavy duty power wheelchair. You say that the enrollee needs this 
because the enrollee's current wheelchair is not working. The Plan denied your request. The Plan says the 
requested wheelchair is not appropriate for the enrollee's weight. 
 
The Plan must follow Medicare rules. Medicare rules say that a power wheelchair is covered if the 
beneficiary's weight is less than or equal to the weight capacity of the power wheelchair that is provided and 
greater than or equal to 95% of the weight capacity of the next lower weight class PWC.  
 
We looked at the file and Medicare rules. The record shows that the enrollee weighs 180 pounds. The requested 
wheelchair is indicated for enrollees weighing 301 to 450 pounds. Based on this information, we decided that 
Medicare rules for coverage of a group 3 heavy duty power wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a group 3 heavy duty power wheelchair (K0851).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation trips. 
 
You asked the Plan to pre-approve the additional transportation. You say that you would like reconsideration 
because you need to go to your chemotherapy appointments. The Plan denied your request. The Plan says 50 
one-way trips per calendar year are covered and the 51st and beyond is 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 Plans coverage rules apply in this 
case. The Plan covers a maximum of 50 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 transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the three (3) office outpatient visits at 25 minutes 
(99214) and three (3) office outpatient visits at 15 minutes (99213) to be provided by an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve office outpatient visits. You say that the Plan's organized network of 
cardiology providers is neither current nor accurate. The Plan denied your request. The Plan says the 
beneficiary is not within a special continued care period; there are in-network providers who are able to provide 
the care needed. 
 
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 
the three (3) office outpatient visits at 25 minutes (99214) and three (3) office outpatient visits at 15 minutes 
(99213) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and a complete 
mandibular denture. 
 
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. The Plan denied your 
request. The Plan says you have exhausted your denture 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, dentures are covered once per arch 
every 5 years. The record shows that you received dentures on April 10, 2017, and your dentures benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture 
and a complete mandibular denture.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #7. 
 
You asked the Plan to pre-approve the crown. You say that the tooth has decay underneath the corroded 
amalgam. You also say that the tooth is fractured. The Plan denied your request. The Plan says that the tooth 
does not appear to have significant breakdown. 
 
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 crown 
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 crown. Our reviewer says that the 
crown is medically reasonable and necessary. Our physician reviewer found the criteria for coverage for a 
crown restoration (D2740) for tooth #7 have been met due to the large restoration, recurrent caries and a crack. 
 
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 crown have been met. Therefore, we decided that the Plan has to pre-
approve a crown (D2740) for tooth #7.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a Computed Tomography (CT) scan of the thoracic spine. 
 
You asked the Plan to pre-approve CT scan. You say that you are in great pain and cannot function. The Plan 
denied your request. The Plan says that the denial of authorization for this service is correct, because this test 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 CT scan. Our reviewer says that you 
meet the Medicare criteria for the requested CT scan. Our physician reviewer found you have a history of 
multi-level back pain. You have a prior history of multi-level spinal surgeries, You are currently undergoing 
evaluation for potential treatments of your most recent complains related to back pain. Your treating physician 
has since ordered this CT scan to evaluate your anatomy and the position of hardware from your prior thoracic 
spine surgery. In this setting it would be considered medically reasonable and necessary for a CT scan of the 
thoracic spine to be completed. Such a study would be useful in making treatment decisions and more 
specifically would allow the treating provider to make a determination on what - if any - intervention could be 
warranted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan have been met. Therefore, we decided that the Plan has to pre-approve 
a Computed Tomography (CT) scan of the thoracic spine.  
 
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: 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 are not able to take showers without this 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture. 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you need your partial denture 
replaced because you can only chew on one side of your mouth. You also say that you do not have any top 
teeth, and only have one tooth on the bottom. The Plan denied your request. The Plan says this service is only 
covered one time in a 60 month time period. The Plan also says that you have already received this service 
within that time period. 
 
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, you are limited to 1 complete or partial 
denture every 5 years. The record shows that you last received a mandibular partial denture on November 6, 
2017, and your mandibular denture benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve a mandibular partial denture.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the podiatry, toe nail trimming services. 
 
You asked the Plan to pay for the podiatry services. You say that you are legally blind and is unable to trim 
your nails properly on your own. You have a history of ingrown toenails and had to have surgery and now your 
other big toe is developing the same issue. The Plan denied your request. The Plan says the enrollee does not 
meet the Medicare criteria as there is no documentation that the enrollee has a systemic disease of sufficient 
severity. 
 
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is 
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or 
feet or have fungal nails.  
 
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for 
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the toe 
nail trimming have not been met. Therefore, we decided that the Plan does not have to pay for the podiatry, toe 
nail trimming services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in tub/shower (E1399). 
 
You asked the Plan to pre-approve a walk-in tub/shower.. You say that the tub is medically necessary because 
of back pain. The Plan denied your request. The Plan says tubs and showers are not covered benefits. 
 
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 walk-in tub/shower (E1399).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a pneumatic compression device identified with code E0651. 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says that the requested device is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that pneumatic compression devices are covered for 
certain indications. 
 
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 pneumatic compression device. Our 
reviewer says that the documentation does support that the requested pneumatic compression device is 
medically reasonable and necessary. Our physician reviewer found the enrollee has lymphedema that has 
persisted despite aggressive adjunctive therapy. The documentation adequately supports the diagnosis of 
lymphedema and the trial of other therapy to relieve lymphedema. Therefore, the enrollee meets criteria for the 
requested 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 a pneumatic compression device have been met. Therefore, we decided that the 
Plan has to pre-approve a pneumatic compression device identified with code E0651.  
 
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve podiatry services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve podiatry services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services can be provided by a network 
provider. 
 
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 
podiatry services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the established patient office or other outpatient visit 
(99213, 99214) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the established patient office or other outpatient visit. You say that the 
network of cardiology providers is neither current nor accurate. The Plan denied your request. The Plan says 
there are multiple providers in-network able to provide the care you need. 
 
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 
the established patient office or other outpatient visit (99213, 99214) to be provided by an out of network 
(OON) provider.
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 this will assist the enrollee with better 
positioning for her body mechanics and reduce the pain. 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 the enrollee does not suffer from diabetic foot disease and does 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 compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the claim should be paid, the 
stockings are required for edema. The Plan denied your request. The Plan says the requested stockings are 
noncovered for all indications because they do not meet the definition of a surgical dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.