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

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921 x4) and application of 
desensitizing medicament (D9910). 
 
You asked the Plan to pre-approve gingival irrigation and application of desensitizing medicament. You say 
that these services are medically necessary. The Plan denied your request. The Plan says these 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. 
 
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 
gingival irrigation (D4921 x4) and application of desensitizing medicament (D9910).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sympathetic nerve block (pain procedure) (64520). 
 
You asked the Plan to pre-approve the pain procedure. You say that you need this injection because you cannot 
walk. The Plan denied your request. The Plan says per LCD rules, nerve blocks are not covered for the 
treatment of pain due to nerve damage. The use of this type of nerve block for any other condition is considered 
experimental. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the pain procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve sympathetic nerve block (pain procedure) (64520).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental CT (computed tomography) scan (D0381), 
porcelain/ceramic crowns (D2740), gum surgery (D4267), bone grafting for implant placement (D6104) and 
collection and application of blood (D7921) 
 
You asked the Plan to pre-approve the dental services. You say that you had this same service on your upper 
teeth last year, and all services were completely covered. You do not understand why you should pay for these 
services this year. The Plan denied your request. The Plan says Plan benefits are subject to change from year to 
year, as approved by Medicare. The requested services are not covered by Medicare or the Plan's supplemental 
dental benefit in 2021. 
 
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 
dental CT scan (D0381), porcelain/ceramic crowns (D2740), gum surgery (D4267), bone grafting for implant 
placement (D6104) and collection and application of blood (D7921)
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Caverject injection. 
 
You asked the Plan to pre-approve Caverject injection. You say that you need this drug for your medical 
condition. The Plan denied your request. The Plan says this drug is not covered under your Medicare Part B 
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 Caverject injection.  
 
Benefits for Caverject injection may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto.
You asked the Plan to pre-approve Entresto. You say that the enrollee has heart failure. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B.
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 Entresto.
Benefits for Entresto may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography angiography of the abdomen/pelvis and 
lower extremities. 
 
You asked the Plan to pre-approve a computed tomography angiography of the abdomen/pelvis and lower 
extremities. You say that the requested computed tomography angiography of the abdomen/pelvis and lower 
extremities is medically necessary. The Plan denied your request. The Plan says that the requested computed 
tomography angiography of the abdomen/pelvis and lower extremities is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 computed tomography angiography of 
the abdomen/pelvis and lower extremities. Our reviewer says that the requested computed tomography 
angiography of the abdomen/pelvis and lower extremities is medically necessary. Our physician reviewer 
found CT angiogram is necessary for evaluation of arteries to tie into for the new allograft (transplanted 
kidney). A CT angiogram is ordered in several cases to evaluate blood flow. The allograft steals blood away 
from the lower extremities as it takes blood that would otherwise go to the legs. CT angiography is ordered on 
a case-by-case basis based on risk of vascular disease in the transplant recipient. Vascular disease is prominent 
in patients with end stage renal disease (dialysis).  
 
It is medically reasonable and appropriate to get both the CTA of the abdomen and pelvis and get the lower 
extremity data due to the high incidence of peripheral vascular disease in dialysis patients. These tests are 
medically indicated and in the best interest of 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 a computed tomography angiography of the abdomen/pelvis and lower 
extremities have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography 
angiography of the abdomen/pelvis and lower extremities.  
 
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional periapical radiographic images (D0230)
provided October 12, 2020.
You asked the Plan to pay for the two periapical x-rays. You say that you cannot afford the cost of the x-rays
and would like the Plan to cover them. The Plan denied your request. The Plan says you have met your
frequency limit for the requested service and therefore the two additional x-rays 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. The Plan covers one periapical
x-ray per calendar year.
We looked at the file, and Medicare rules. The Plan has covered on periapical x-ray provided October 12, 2020.
Based on this information, we decided that the Plan does not have to pay for the two additional periapical
radiographic images (D0230) provided October 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation systems are not covered.  
 
We looked at the file and Medicare rules. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation to the SI joint (64625). 
 
You asked the Plan to pre-approve the radiofrequency ablation. You say that you would like to be off the 
Tramadol and if the RFA helps you, you would really like to have this procedure to treat the pain. The 
diagnostic tests indicate you would be helped with the RFA. The Plan denied your request. The Plan says the 
doctor has requested a service that research has not proven to be helpful. It is considered experimental or 
investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have 
to pre-approve radiofrequency ablation to the SI joint (64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper extremity orthosis to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says necessary care is 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 services at issue in this appeal. Codes used in describing a prosthetic device, or a lower limb device are not applicable for the requested orthosis. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve an upper extremity orthosis to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift. 
 
You asked the Plan to pre-approve a stair lift. You say that you are appealing because the enrollee cannot walk 
up the stairwell to his bedroom. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required 
(D2950 x2). 
 
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this service 
is not covered under the enrollee's benefit plan. 
 
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 two 
core buildups, including any pins when required (D2950 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Dexcom G6 receiver device. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says adjustments must be made based on blood sugar testing results. 
 
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 device. 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 record indicates the enrollee is not taking insulin and checks the blood sugar twice a day. 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Dexcom G6 receiver device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device and garments.

You asked the Plan to provide a pneumatic compression device (E0652) and garments (E0667). You say that a trial of the device E0652 was completed and showed significant results. The Plan denied your request. The Plan says there is no record of a trial with a basic pneumatic compression pump.

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. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device and garments.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for contrast material provided by a 
participating provider on December 23, 2020. 
 
You asked the Plan to waive the coinsurance for contrast material. You say that you did not know you would 
be charged for the contrast material. The Plan denied your request. The Plan says the correct coinsurance has 
been applied. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for contrast material. The total allowed 
amount is $1,783. The total amount you are being asked to pay is $356.60 ($1,783 x 20% = $356.60). Contrast 
material falls within the Medicare Part B prescription drugs/in-network 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 contrast material provided by a participating provider on December 
23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two surgical procedures for isolation of a tooth with
rubber dams (D3910 x2) and two canal preparations and fittings of preformed dowels or posts (D3950 x2).

You asked the Plan to pre-approve the surgical procedures and canal preparations and fittings. The Plan denied
your request. The Plan says these services are not covered under the enrollee's benefit plan.

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 two
surgical procedures for isolation of a tooth with rubber dams (D3910 x2) and two canal preparations and
fittings of preformed dowels or posts (D3950 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compression device (E0652) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the pneumatic compression device. You say that you would like reconsideration because you are the only provider that supplies this equipment. The Plan denied your request. The Plan says there are in-network providers that can provide this equipment.

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 pneumatic compression device (E0652) 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 30 Acupuncture visits.

You asked the Plan to pre-approve the Acupuncture services. The Plan denied your request. The Plan says this
is not a covered benefit.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for Acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20
sessions per year.

We looked at the file and Medicare rules. The records show that the requested Acupuncture services are for foot
pain. Acupuncture services are not covered for foot pain. Based on this information, we decided that the rules
for coverage of the Acupuncture services have not been met. Therefore, we decided that the Plan does not have
to pre-approve 30 Acupuncture visits.
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 device. You say that the enrollee has failed conservative
approaches to treatment. The Plan denied your request. The Plan says there is not clear medical support for
using 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 device. Our physician
reviewer found that the requested device is experimental. More research is needed to show its safety and
efficacy. Therefore, the requested device is not medically reasonable and 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 device. have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous spacer device.
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 would like reconsideration because these orthotics are required to help your pain while walking. 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.