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

 
We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedure, by 
report (D5899), complete denture - mandibular (D5120), and complete denture - maxillary (D5110) provided 
on November 30, 2020. 
 
You asked the Plan to pay for the complete set of dentures. You say that you cannot afford the cost of the 
services and would like the Plan to provide coverage. The Plan denied your request. The Plan says the services 
are not covered under your 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 pay for the 
unspecified removable prosthodontic procedure, by report (D5899), complete denture - mandibular (D5120), 
and complete denture - maxillary (D5110) provided on November 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a CardioMEMS device. 
 
You asked the Plan to pre-approve CardioMEMS. You say that a study has demonstrated the safety and 
efficacy of CardioMEMS. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because studies have not proven that CardioMEMS is helpful for treatment of the enrollee's 
condition. 
 
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 CardioMEMS. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further 
clinical study is needed to determine the safety and efficacy of this device. The documentation does not support 
that there has been one or more heart failure hospitalization in the past 12 months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CardioMEMS have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of a CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the cardiovascular procedure provided on 
August 15, 2020 and September 24, 2020. 
 
You asked the Plan to waive the coinsurance for the cardiovascular procedures. You say that you were sent to 
this hospital in an emergency situation and there was no discussion on network status of the provider. You say 
that you do not have the ability to pay the out-of-network bills. The Plan denied your request. The Plan says the 
coinsurance 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 20% 
coinsurance for surgery services at an out-of-network outpatient hospital. 
 
You have been asked to pay a total of $287.13 for the cardiovascular procedures.  
 
Date of Service Service Allowed Amount Coinsurance Member Liability 
August 15, 2020 Cardiovascular Procedure $777.09 20% $155.42 
August 15, 2020 Sedation $12.20 20% $2.44 
September 24, 2020 Cardiovascular Procedure $634.16 20% 126.83 
September 24, 2020 Sedation $12.20 20% $2.44 
TOTAL:    $287.13 

The cardiovascular procedures fall within the "Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers" 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 
coinsurance for the cardiovascular procedure provided on August 15, 2020 and September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. The item at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain fused crown and endodontic therapy for
tooth 8.
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 the services are not medically necessary.
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 these services
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the documentation indicates the
presence of three maxillary teeth. None of these teeth appear to be adequate for use as abutment retainers for a
prosthesis. The documentation does not support the need for a root canal (D3310) and crown (D2750) for tooth
#8.
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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a porcelain fused crown and endodontic therapy for tooth 8.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 5, 2020.
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 5, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial maxillary denture (D6213).
You asked the Plan to pre-approve a partial maxillary denture. You say that you are struggling to eat and cannot speak due to having no back teeth support. The Plan denied your request. The Plan says your teeth are not stable enough for the requested denture. The Plan has indicated a different type of denture may be considered if requested.
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 a partial maxillary denture 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 a partial maxillary denture. Our reviewer says that the requested dentures are not medically necessary. Our physician reviewer found the submitted records and imaging are insufficient to determine whether a maxillary partial denture is a reasonable option for you in this case. There appears to be significant dental pathology making a maxillary partial denture not medically reasonable and necessary. 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 a partial maxillary denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture (D6213)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre 14 day sensor kit. 
 
You asked the Plan to pre-approve the services. You say that coverage cannot be authorized at this time. The 
Plan denied your request. The Plan says coverage cannot be authorized at this time. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this case, the enrollee is not on insulin. The elements of the local coverage determination are not 
satisfied. The requested service cannot be recommended. 
 
 
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 the Freestyle Libre 14 day sensor kit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C 40mg/400ml (96365, 96366, J1561). 
 
You asked the Plan to pre-approve Gamunex-C. You say that Gamunex-C is medically necessary. The Plan 
denied your request. The Plan says a trial of Hizentra and Privigen is required before alternatives can be 
considered. 
 
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 Gamunex-C. Our reviewer says that 
Gamunex-C is not medically necessary. Our physician reviewer found the record shows no trial of the plan 
preferred drug or any reason why it would be unsafe or ineffective for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gamunex-C have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gamunex-C 40mg/400ml (96365, 96366, J1561).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a hearing aid processor (CPT code L8691), for the enrollee. 
 
You asked the Plan to pre-approve the processer. You say that this is being requested due to the enrollee's 
sensorineural hearing loss. The Plan denied your request. The Plan says that only certain devices are payable by 
Medicare as prosthetic devices. 
 
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 processer. Our physician reviewer 
found Medicare does cover bone conduction devices which are devices that provide mechanical energy to the 
cochlea via stimulation of the scalp with amplified mechanical vibration or by direct contact with the tympanic 
membrane or middle ear ossicles. Medicare does not have specific criteria to be eligible for a BAHA. The 
enrollee does not suffer from SSD (single sided deafness), so the criteria for SSD should not be used in this 
case. The enrollee suffers from asymmetrical hearing loss on the right. By definition, SSD means that the 
hearing on the better ear is close to normal, which is not the case with this enrollee. The enrollee is currently 
benefiting from a BAHA because of the degree of hearing loss on the right. If the current processor needs to be 
replaced, as deemed by his audiologist, then it is medically necessary to replace the device. It is covered by 
Medicare because it is a BAHA and not a hearing aid. 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 processer have 
been met. Therefore, we decided that the Plan has to pre-approve a hearing aid processor (CPT code L8691), 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jardiance. 
 
You asked the Plan to pre-approve Jardiance. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not a covered benefit. 
 
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 Jardiance.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional ten physical therapy visits for the enrollee. 
 
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee's pain and function remain largely unchanged due to 
rehabilitation efforts. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the additional visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found based on the medical records provided there is no documentation that 
the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based 
on the available records the enrollee appears to have improved with therapy essentially to the point of meeting 
strength and range of motion goals. Transition to the home exercise program appears appropriate at this point. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an additional ten physical therapy visits for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (TOF - testing to monitor the depth of muscle relaxation during surgery) (CPT code 95999) provided to the enrollee.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says Medicare guidelines say that this item or service is considered a bundled procedure as the cost is included in the cost of the primary procedure.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 95999 has a bundled relationship with (CPT) code(s): G0453, 95938, 95957, 95870, and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (TOF - testing to monitor the depth of muscle relaxation during surgery) (CPT code 95999) provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and a tooth 
extraction (D7210) to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve an oral evaluation and tooth extraction. You say that you need the Plan's 
assistance in covering this service because your tooth broke and you are in pain. The Plan denied your request. 
The Plan says rules for coverage of the requested services have not been met. 
 
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 an oral 
evaluation and tooth extraction when performed by a participating general dentist.  
 
We looked at the file and Medicare rules. The record shows that the requested services are to be performed by 
an oral surgeon rather than a general dentist. Based on this information, we decided that the Plan's rules for 
coverage of an oral evaluation and tooth extraction have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a comprehensive oral evaluation (D0150) and a tooth extraction (D7210) to be 
performed by an oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services.

You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are avoiding reconstruction of your feet by 
having inserts. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed 
 
You asked the Plan to pre-approve the semi-electric hospital bed. You say that you need the semi-electric bed 
for medical necessity. The Plan denied your request. The Plan says there is no documentation that the member 
requires frequent or immediate changes in position supportive of the need for a semi-electric bed. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 
 
2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 semi-electric hospital bed. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found in order to qualify for a 
semi-electric hospital bed, the patient?s condition must require frequent change in body position and/or there 
may be an immediate need for a change in body position (i.e., no delay can be tolerated) and the patient can 
operate the controls and cause the adjustments. Exceptions may be made to this last requirement in cases of 
spinal cord injury and brain damaged patients. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Medicare National Coverage Determinations Manual, Section 280.7(D). 
 
The review has determined that the enrollee's condition does not require position of the body in ways not 
feasible in an ordinary bed. The enrollee's condition does not require special attachments that cannot be fixed 
and used on an ordinary bed. The requested semi-electric hospital bed is not medically necessary for this 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural injection without imaging guidance. 
 
You asked the Plan to pre-approve epidural or subarachnoid, lumbar or sacral (caudal); without imaging 
guidance (62322). You say that you need this injection for pain relief. The Plan denied your request. The Plan 
says no image guidance is being used and that is not safe. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. The requested injection is an epidural injection without imaging. 
Based on this information, we decided that Medicare rules for coverage of epidural injection have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an epidural injection without imaging 
guidance.