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

 
We decided that the Plan does not have to pre-approve a white glass crown (D2740). 
 
You asked the Plan to pre-approve a white glass crown. You say that this will keep you from needing a root 
canal. The Plan denied your request. The Plan says this is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
white glass crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power mobility device. 
 
You asked the Plan to pre-approve a power mobility device. You say that you need a power mobility device for 
after your surgery. The Plan denied your request. The Plan says you do not meet criteria for a motorized 
scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show you have a mobility deficit that impairs your participation in MRADLs, your condition 
cannot be improved by a walker, cane or manual wheelchair, or that you can safely operate the PMD being 
requested. There is no physician order, face-to-face documentation, or home assessment documentation. This 
means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power mobility device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that the shower chair is medically necessary. The 
Plan denied your request. The Plan says shower chairs are not covered items. 
 
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 the implant procedure, tooth 25 (D6199). 
 
You asked the Plan to pre-approve the implant procedure. You say that this procedure is medically necessary 
for the enrollee. 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. 
 
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 
implant procedure, tooth 25 (D6199).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee needs a total electric 
hospital bed to move around and get out of bed. The Plan denied your request. The Plan says a total electric 
hospital bed is not covered by the Plan or Medicare because the height adjustment feature is a convenience. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
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 monitor. You say that this is needed to check your blood pressure at 
home. The Plan denied your request. The Plan says you are not receiving home dialysis. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 
medical services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a patient lift (E0635). 
 
You asked the Plan to pre-approve a patient lift. You say that the lift the enrollee has doesn't get her high 
enough. The Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a patient lift is covered if transfer between bed and a 
chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary would be bed confined. 
The rules also say that Medicare considers equipment to be reasonable and necessary if the equipment does not 
serve the same purpose as other equipment already available to an enrollee. 
 
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 patient lift. Our reviewer says that the 
enrollee does not meet Medicare coverage criteria for the requested heavy duty lift. Our physician reviewer 
found the documentation does not support that it is medically reasonable and necessary.  There is no 
documentation regarding her transfer ability between the bed and a chair/wheelchair/commode or if the 
enrollee is bed-confined and requires supine positioning for transfers. The documentation by the physician does 
not support or details functional deficits, limitations or justification for a heavy duty lift. 
 
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 patient lift have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a patient lift (E0635).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ear services to be provided by an out of network (OON) 
provider. 
 
You asked the Plan to pre-approve ear services. You say that you would like approval for these services. The 
Plan denied your request. The Plan says there are in-network providers available for 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 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 
ear services 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 routine transportation services. 
 
You asked the Plan to pre-approve routine transportation. You say that you were told that these drivers have a 
contract with the Plan-approved transportation provider. The Plan denied your request. The Plan says the denial 
of authorization for this routine transportation is correct, because routine transportation must be performed by 
the Plan-approved transportation provider. 
 
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 routine transportation when provided by the Plan's routine transportation provider.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve routine transportation services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve bilateral lumbar epidural steroid injections (ESIs). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that lumbar ESIs are covered when specific criteria 
are 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has chronic low back pain with 
radicular symptoms. She has had two prior ESIs that both provided 50 percent pain relief for more than eight 
weeks. The criteria for coverage of a repeat ESI have been met and the procedure is reasonable and medically 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve bilateral lumbar epidural steroid injections (ESIs).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat lift feature (E2300). 
 
You asked the Plan to pre-approve the power seat lift. You say that the lift feature is medically necessary. The 
Plan denied your request. The Plan says seat lift features are not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is non-
covered.  
 
We looked at the file and Medicare rules. This feature is not a covered item. Based on this information, we 
decided that Medicare rules for coverage of the power seat lift have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a power seat lift feature (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve filling for a crown with posts, teeth 3 and 4 (D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you were under the impression that prep 
work before a crown was put in was a covered benefit and nothing in the Evidence of Coverage mentions that. 
If you had known you would've had your options open. 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. 
 
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 
filling for a crown with posts, teeth 3 and 4 (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve DUROLANE (J7318). 
 
You asked the Plan to pre-approve DUROLANE. You say that this is medically necessary. The Plan denied 
your request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 DUROLANE. Our reviewer says that 
the criteria for coverage of DUROLANE has not been met. Our physician reviewer found the Plan requires a 
trial of Monovisc and Orthovisc before they will approve the requested drug. The enrollee has not trialed 
Orthovisc and Monovisc. The documentation does not outline contraindications or reasons these medications 
were not considered. 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of DUROLANE have not been met. Therefore, we decided that the Plan does not 
have to pre-approve DUROLANE (J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on April 8, 2020 
to May 6, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like this claim 
reprocessed and approved for payment. You say that you were told all your providers were in-network when 
you signed up for this Plan. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided on 
April 8, 2020 to May 6, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the removal of a foreign body from tissue 
(10120) performed on May 21, 2020. 
 
You asked the Plan to waive the deductible for the removal of a foreign body from tissue. You say that the 
office visit was too brief for the amount you are being charged. The Plan denied your request. The Plan says 
you were charged correctly and that the charges were correctly applied to your annual deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible you must pay for medical services before the Plan 
begins to pay its share.  
 
The item or service for which you asked the Plan to waive the deductible falls within the benefit category 
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers." The Plan has followed Medicare rules by clearly disclosing in the contract that the $750 deductible 
applies to this benefit category. This cost sharing is a contractual obligation that had not been met at the time 
the removal of a foreign body from tissue was performed on May 21, 2020. Therefore, we decided that the Plan 
does not have to waive the deductible for the removal of a foreign body from tissue (10120) performed on May 
21, 2020.  
 
Your complaint about the provider overcharging the Plan for a 5-minute office visit 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: 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 feel that this is medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Dexcom G6 transmitter. 
 
You asked the Plan to pay for a Dexcom G6 transmitter. You say that this is medically necessary. The Plan 
denied your request. The Plan says that there is no documentation that you meet criteria for coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above 
criteria have been met. Medicare rules also say that information must be submitted to confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. The case file did not include medical records. The case file shows 
that the Plan sent notification that this medical documentation was needed. Without medical records, we cannot 
make a determination regarding medical necessity and you have not proven that Medicare coverage criteria for 
Dexcom G6 transmitter have been met. Based on this information, we decided that Medicare rules for coverage 
of a Dexcom G6 transmitter have not been met. Therefore, we decided that the Plan does not have to pay for a 
Dexcom G6 transmitter.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250). 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the service is necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 chest. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the 2020 NCCN guidelines do 
not support the use of chest CT in a patient classified as low-intermediate risk, a group in which this patient 
falls based upon the biopsy results. While imaging of the abdomen and pelvis, as already approved, remains in 
the established guidelines, CT of the chest does not. 
 
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 chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the chest (71250).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acute hospital services provided to the enrollee on January 8, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says non-urgent services should be from network providers who are contracted with 
the healthplan and listed in the Provider Directory. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for acute hospital services provided to the enrollee on 
January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on December 4, 2019 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that the services were medically necessary The Plan denied 
your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan and the enrollee self-directed for care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on December 4, 
2019 by an out of network (OON) provider.