Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider.
 
You asked the Plan to pre-approve OON services. You say that the enrollee has a relationship with this 
provider. The Plan denied your request. The Plan says the requested 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 
the medical services 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 pay for the portable oxygen concentrator provided on May 7, 2020. 
 
You asked the Plan to pay for the concentrator. You say that it was advertised that insurance would pay for 
most of the cost. The Plan denied your request. The Plan says the provider does not accept Medicare 
assignment. 
 
The Plan must follow Medicare rules. Medicare rules say that contractors may not pay for oxygen equipment 
that is purchased. 
 
We looked at the file and the rules. Payment is not made for purchases of this type of equipment. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the portable oxygen concentrator provided on May 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom oral appliance. 
 
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. 
 
The Plan must follow Medicare rules. Medicare rules say that an oral appliance is 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 not medically necessary. Our physician reviewer found the submitted records show that you 
have severe obstructive sleep apnea (OSA). The continuous positive airway pressure (CPAP) device study 
showed that the CPAP is effective in correcting your sleep-disordered breathing. The records do not show that 
the CPAP is ineffective or that you are unable to use it. The criteria for coverage of the oral appliance are not 
met and the services are not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a custom oral appliance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sauna. 
 
You asked the Plan to pre-approve the sauna. You say that you have Parkinson's diseases, soreness, pain, and 
very impaired movement. The Plan denied your request. The Plan says this is not primarily medical in nature. 
 
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 sauna.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
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. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has lumbar radiculopathy. 
There is no specific clinical rationale for the requested MRI. The physical exam does not document any 
concerning neurologic findings. There are no complaints of leg or back weakness or pain, and no limitation of 
function. Positional parethesias during sleep are not typically suspicious for underlying spinal pathology in the 
absence of other symptoms. The MRI is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea weight scale.You asked the Plan to pre-approvethese services. You say that your doctor stated you need to lose weight.The Plandenied your request. The Plan says the services are not covered.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-approvea weight scale.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the flexible sigmoidoscopy provided on 
July 24, 2020. 
 
You asked the Plan to waive the copayment for the sigmoidoscopy. You say that this service should be 100% 
covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $300 
copayment for ambulatory surgical center and outpatient hospital visits.  
 
You have been asked to pay a $300 copayment for the sigmoidoscopy. The sigmoidoscopy falls within the 
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical 
centers benefit category. The medical record shows the sigmoidoscopy was performed because of a positive 
Cologuard test which makes the procedure medical in nature. 
 
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 flexible sigmoidoscopy provided on July 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture-flexible base (D5225) and 
mandibular partial denture-flexible base (D5226). 
 
You asked the Plan to pre-approve maxillary and mandibular partial denture. You say that the services are 
medically necessary. The Plan denied your request. The Plan says the services are not a covered 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. The Plan only covers services 
listed on the Covered Dental Codes for Medicare Enhanced Benefits chart.  
 
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. Specifically, the service requested is not considered a basic partial 
denture and is not listed on the benefits chart for your supplemental coverage. Therefore, we decided that the 
Plan does not have to pre-approve maxillary partial denture-flexible base (D5225) and mandibular partial 
denture-flexible base (D5226).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an inflatable penile prosthesis. 
 
You asked the Plan to pre-approve the penile prosthesis placement. You say that this is a necessary step in 
order to definitively treat your condition. The Plan denied your request. The Plan says at least one other erectile 
dysfunction treatment must be trialed before this can be considered reasonable and 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 the penile prosthesis placement. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found in this case, the enrollee has attempted the PDE5 inhibitor, Viagra and 
received treatment for hypogonadism. Secondary treatments, such as noted in Up to Date, such as vacuum 
devices, penile self-injectable drugs, and intraurethral alprostadil should be as second-line therapy before 
surgical intervention is considered. American Urological Association guidance is similar. Therefore, based 
upon the current documentation, the requested therapy exceeds the medical need and cannot be recommended 
for coverage under Medicare rules. 
 
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 penile prosthesis placement have not been met. Therefore, we decided that 
the Plan does not have to pre-approve insertion of an inflatable penile prosthesis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751). 
 
You asked the Plan to pre-approve a crown. You say that you are unable to eat regular food due to your 
damaged tooth. 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 
crown (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the drugs or medicaments dispensed in the office for home 
use or make additional payment for the scaling in presence of generalized moderate or severe gingival 
inflammation provided on July 13, 2020. 
 
You asked the Plan to pay for the drugs or medicaments and scaling. You say that these procedures were vital 
to your health. The Plan denied your request. The Plan says the drugs or medicaments are not a covered 
benefit. The Plan also says that you are responsible for a 70% coinsurance for the scaling. 
 
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 drugs or medicaments dispensed in 
the office for home use is not among those covered under this benefit. The contract also clearly states that you 
must pay a 70% coinsurance for periodontal scaling and root planing. Therefore, we decided that the Plan does 
not have to pay for the drugs or medicaments dispensed in the office for home use or make additional payment 
for the scaling in presence of generalized moderate or severe gingival inflammation provided on July 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device. 
 
You asked the Plan to pre-approve the requested services. You say that the minimally invasive procedure is 
recommended as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. 
The Plan says there is insufficient reliable evidence to establish the safety and efficacy of the device. 
 
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 requested services. Our physician 
reviewer found that the device is considered experimental. There is insufficient reliable evidence to establish 
the safety and efficacy of the device. Therefore, the requested service 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous spacer device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from 
February 29, 2020, through March 3, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The 
Plan says prior authorization was not obtained by the provider or facility. The provider should have verified the 
member?s eligibility, health benefits and obtained authorization prior to the member?s visit before providing 
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 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 a behavioral health inpatient admission provided from February 
29, 2020, through March 3, 2020.
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 this is medically necessary for your left leg 
amputee. 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan of the chest rendered. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that inpatient hospital services must be billed with 
POS code 21. 
 
We looked at the file and Medicare rules. The file shows that the enrollee was under inpatient status for the 
date of service at issue. The claim for procedure code 71250 was incorrectly billed with POS code 22 for 
outpatient hospital. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography 
(CT) scan of the chest rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tdap and shingles vaccines you received.

You asked the Plan to pay for the vaccines. You say that you thought this was covered as a preventive service. The Plan denied your request. The Plan says these vaccines are not covered under your Part B plan.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines. The Plan follows the same rules. 

The records do not show that you have been injured or directly exposed to any illness related to the vaccines. Therefore, we decided that the Plan does not have to pay for the Tdap and shingles vaccines you received. 

Sincerely,

Office of the Project Director Medicare Managed Care & PACE Reconsideration Project
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation with a periodontist. 
 
You asked the Plan to pre-approve the consultation. You say that this is medically necessary and needed as 
soon as possible to avoid an infection. The Plan denied your request. The Plan says this is not a covered benefit 
with this provider. 
 
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 dental 
services as long as they are provided by a participating general dentist.  
 
The requested services are to be provided by a periodontist, not a general dentist. Based on this information, we 
decided that the Plan's rules for coverage of the consultation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a consultation with a periodontist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 4, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
laboratory services. 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 laboratory services provided on September 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180), four 
gingival irrigations (D4921 x4), and four applications of desensitizing resin (D9911 x4). 
 
You asked the Plan to pre-approve the comprehensive periodontal evaluation, gingival irrigations, and 
applications of desensitizing resin. The Plan denied your request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive periodontal evaluation (D0180), four gingival irrigations (D4921 x4), and four applications of 
desensitizing resin (D9911 x4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal deep cleaning and a tooth extraction. 
 
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 exceed the benefit limits. 
 
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 maximum 
plan benefit coverage amount of $500 per year. 
 
We looked the file and the Plans rules. The file shows that you had dental services on August 21, 2020 and 
August 24, 2020 for which the Plan approved and paid. At this time, you had used your full $500 benefit limit 
for supplemental dental services. Further services are not covered by your supplemental dental benefit or 
medical benefit. The extraction is not covered by your medical benefit because it is not being done to prepare 
the jaw for radiation treatment. 
 
Therefore, we decided that the Plan does not have to pre-approve periodontal deep cleaning and a tooth 
extraction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PureWick Urine Collection System. 
 
You asked the Plan to pre-approve the PureWick Urine Collection System. You say that you need this system 
because of your medical condition. The Plan denied your request. The Plan says the PureWick system is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. This brand of urinary collection device is not covered by Medicare. 
Medicare rules say that items that do not meet Medicare requirements are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the PureWick Urine Collection System have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the PureWick Urine Collection System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wound therapy pump (E2402, A6550). 
 
You asked the Plan to pre-approve the wound therapy pump. You say that the wound pump is medically 
necessary. The Plan denied your request. The Plan says coverage for this item has been exhausted. 
 
The Plan must follow Medicare rules. Medicare rules say that a Negative Pressure Wound Therapy pump and 
supplies will be denied as not reasonable and necessary when used for more than four (4) months on the most 
recent wound. 
 
We looked at the file and Medicare rules. The pump has already been used for four months. Based on this 
information, we decided that Medicare rules for coverage of the wound therapy pump have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a wound therapy pump (E2402, A6550).