Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the motorized scooter. 
 
You asked the Plan to pre-approve the motorized scooter. You say that you would like reconsideration because 
the scooter will help you move around your home. The Plan denied your request. The Plan says there is no 
evidence that you are unable to participate in MRADLs or that your home provides adequate access between 
rooms, maneuvering space and surfaces for the operation of the 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.  
 
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 motorized scooter. Our reviewer 
says that the documentation does not reveal that you have a personal mobility deficit that impairs participation 
in MRADLs in the home. Our physician reviewer found the documentation does not reveal why your mobility 
deficit is unable to be helped by a walker, cane, or manual wheelchair.  The documentation is not clear that you 
can safely  maneuver the power operated vehicle  in the home or that the requested scooter will significantly 
improve ADL performance in the home. 
 
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 motorized scooter have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the motorized scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic substrate, teeth 21, 22, 23, 
24, 25, 26, 27 (D2740) core build-up, including pins, teeth 20, 21, 22, 23, 24, 25, 26, 27, 28, 31 (D2950) 
abutement supported porcelain/ceramic crown, tooth 20 (D6058) pontic, porcelain/ceramic, teeth 18, 19, 29, 30 
(D6245) and bone replacement graft, tooth 30 (D4263). 
 
You asked the Plan to pre-approve the dental services. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says these services are 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. Services not listed is not 
covered by the plan. 
 
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 
crown - porcelain/ceramic substrate, teeth 21, 22, 23, 24, 25, 26, 27 (D2740) core build-up, including pins, 
teeth 20, 21, 22, 23, 24, 25, 26, 27, 28, 31 (D2950) abutement supported porcelain/ceramic crown, tooth 20 
(D6058) pontic, porcelain/ceramic, teeth 18, 19, 29, 30 (D6245) and bone replacement graft, tooth 30 (D4263).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided  on May 9, 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 May 9, 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 May 9, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy and crown and core buildup. 
 
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 covered. 
 
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, 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 
endodontic therapy and crown and core buildup.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Lipiflow procedure. 
 
You asked the Plan to pre-approve the Lipiflow procedure. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says this service is 
experimental. 
 
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 Lipiflow procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Lipiflow procedure remains experimental/investigational 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 the Lipiflow procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Lipiflow procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CT capture and interpretation (D0364). 
 
You asked the Plan to pre-approve the CT capture and interpretation. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says this is 
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. 
 
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 
CT capture and interpretation (D0364).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial denture (D5820), a bone replacement 
graft (D7953), guided tissue regeneration (D4266), and a retainer (D6795). 
 
You asked the Plan to pre-approve an interim partial denture, a bone replacement graft, guided tissue 
regeneration, and a retainer. You say that you need these services because you have been in pain for years. 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 an 
interim partial denture (D5820), a bone replacement graft (D7953), guided tissue regeneration (D4266), and a 
retainer (D6795).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for out-of-network services at the in-network 
benefit level for one year. 
 
You asked the Plan to pre-approve the referral. You say that this should be approved for the period of 1/1/21 
through 12/31/21, if not indefinitely. The Plan denied your request. The Plan says the enrollee has a plan and 
benefits are available for out-of-network providers and facilities at a higher cost. 
 
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 at the in-network benefit level 
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  same level of as the requested services at issue in this appeal. We found no 
exception that would require the Plan to pre-approve these services at the in-network benefit level. Therefore, 
we decided that the Plan does not have to pre-approve a referral for out-of-network services at the in-network 
benefit level for one year.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (CPT 15003) provided to the enrollee on 
April 15, 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 CPT 15003 was not supported in the medical records submitted. 
 
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, the CPT Code Manual definition of code 15003 is "Surgical preparation or creation of recipient 
site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of 
scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body 
area of infants and children (List separately in addition to code for primary procedure)." 
 
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 pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found CPT 
15003 cannot be verified in the operative report as a separate procedure. Debridement is included in the 
primary code, and is not separately reported. 
 
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 pay for surgical services (CPT 15003) provided to the enrollee on April 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bifocal lenses (V2202) received on August 19, 2020. 
 
You asked the Plan to pay for bifocal lenses. You say that a representative of the Plan informed you the 
provider was a covered provider and that no one advised you of the change in the provider's network status. 
The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when received from a Plan optical facility. 
 
We looked at the file and the Plan's rules. In this case, the provider is not a network provider. Based on this 
information, we decided that the Plan's rules for coverage of bifocal lenses have not been met. Therefore, we 
decided that the Plan does not have to pay for bifocal lenses (V2202) received on August 19, 2020.  
 
Your complaint about receiving erroneous or misleading information about your benefit from a representative 
of the Plan 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided at. on July 8, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you want this bill to be paid by your 
provider. 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 8, 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 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the alveoloplasty (URQ, ULQ, LLQ, LRQ) (D7311). 
 
You asked the Plan to pre-approve the dental service. You say that the records provided should support the 
necessity of the services in dispute. 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 Plans coverage rules apply in this case. Services not listed is not 
covered by the plan. 
 
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 
alveoloplasty (URQ, ULQ, LLQ, LRQ) (D7311).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for a pneumatic compression device (E0652). 
 
You asked the Plan to provide coverage for a pneumatic compression device. You say that this device is 
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. Based on the medical records provided, there is 
no record of the completed four-week trial needed of the basic device. Medicare coverage criteria are not met.  
Therefore, we decided that the Plan does not have to provide coverage for a pneumatic compression device 
(E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services you received from August 24, 2020, to August 
31, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted 
out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
services you received from August 24, 2020, to August 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to provide Privigen (J1459). 
 
You asked the Plan to provide Privigen (J1459). You say that you want the enrollee treated with this drug. The 
Plan denied your request. The Plan says the use of Privigen for the treatment of the enrollee's condition is not 
supported by literature and is not medically indicated. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 provide Privigen (J1459). Our reviewer says that the 
drug is not medically necessary. Our physician reviewer found IVIG is not FDA approved for small fiber 
neuropathy or autoimmune autonomic neuropathy.  IVIG is not supported for use in the Medicare accepted 
Compendia for either diagnosis. The Compendia are silent on the proposed use of the medication.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Privigen (J1459) have not been met. Therefore, we decided that the Plan does 
not have to provide Privigen (J1459).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve the 6 additional visits. You say that you would like reconsideration because the 
additional therapy is medically necessary. The Plan denied your request. The Plan says there is nothing in the supplied 
documentation that supports that the services will be of such a level of complexity and sophistication, or the condition of 
the patient will be such that the services required can be safely and effectively performed only by a qualified therapist or 
under a therapist's supervision after the total approved visits. 
 
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 6 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 you have already been authorized additional sessions to review an independent exercise program. The 
specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
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 6 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-
approve 6 additional physical therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the insertion of an abdominal cavity 
catheter for drainage or dialysis (49421) provided on July 14, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $450 
copayment for outpatient surgery at a hospital facility.  
 
You have been asked to pay a $450 copayment for the outpatient surgery provided at a hospital facility. 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 insertion of an abdominal cavity catheter for drainage or 
dialysis (49421) provided on July 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox 200 units every 3 months for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that the patient does not meet the criteria for Botox 200 unit vial 
because the patient does not have 14 of more headaches per month. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 
Botox 200 units every 3 months is not medically reasonable and necessary for the enrollee in this case. In this 
case the member was noted to have chronic muscle tension headaches. The member's headache frequency was 
also noted to only be three times per week. In this setting it cannot be said that the member has a diagnosis of 
chronic migraine headaches. First, the headaches were not described as being migranous. Second, the 
frequency of headaches is below that which is required by diagnostic criteria for chronic migraine. Botox has 
been studied for use in multiple types of headache disorders. However, it has only been shown to be beneficial 
in the prophylaxis of chronic migraine. It is not recognized as having efficacy in episodic migraine or tension 
headaches. As the member has not been prescribed this medication for a condition for which it is known to be 
safe and/or effective for use, it would not be reasonable and necessary. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox 200 units every 3 months for the enrollee.
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 unable to walk any distances. 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.