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

We decided that the Plan does not have to pre-approve electronic connection between two or more power 
seating system motors (E2311) expandable controller (E2377) and harness (E2313) seat elevator (E2300). 
 
You asked the Plan to pre-approve the seat lift and upgraded electronics. You say that please review the 
attached medical documentation to support the need of the custom medical equipment being requested. The 
Plan denied your request. The Plan says the seat lift does not serve a medical purpose and is not covered. The 
upgraded electronics are not medically 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 seat lift and upgraded electronics. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has 4/5 strength in her upper extremities. She is reported to 
be independent with feeding and grooming and set-up assist for upper body dressing. Her upper extremity 
strength and function appear to be adequate to control the power options using their own switches which are 
included in the allowance of these power options. Based on the medical records provided there is no 
documentation that the requested items are 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 seat lift and upgraded electronics have not been met. Therefore, we decided 
that the Plan does not have to pre-approve electronic connection between two or more power seating system 
motors (E2311) expandable controller (E2377) and harness (E2313) seat elevator (E2300).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine transportation services. 
 
You asked the Plan to pre-approve the routine transportation services. You say that the enrollee does not have 
any other means of transportation that would not endanger his health. You say that the enrollee needs 
transportation to appointments with his renal and cardiology specialists. You say that the enrollee is not able to 
see his physicians in a timely manner. You say that the enrollee cannot sit up and is homebound. You say that 
the enrollee has been seeing the requested specialists for 10 years and that he wants to continue care with them 
as they are familiar with his chronic conditions. The Plan denied your request. The Plan says the transportation 
services being requested do not meet the benefit limitations or criteria for coverage. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when immediately following hospital discharges and when each 
one-way trip does not exceed 50 miles.  
 
We looked at your request, the records in the case file, and the rules. The records show that you are requesting 
routine transportation services for the enrollee to see his current specialists once he moves from Albuquerque 
to Santa Fe. The records do not show that the routine transportation being requested is for after a hospital 
 
 
discharge or within 50 miles of the enrollee's home address. Based on this information, we decided that the 
Plan?s rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does 
not have to pre-approve routine transportation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0367) 
provided. 
 
You asked the Plan to pay for the cone beam CT. You say that these services were preliminary to a necessary 
dental surgery. You also say that dental surgery is covered. The Plan denied your request. The Plan says cone 
beam CT capture and interpretation is not listed as a covered service. 
 
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 cone 
beam CT capture and interpretation (D0367) provided.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the COVID-19 test provided to the enrollee on June 12, 2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says that this test is not covered for the enrollee's diagnosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not supported and substantiated their denial. They have not 
provided a Medicare-approved source to deny this test. There is no evidence of a Medicare source that shows 
that the COVID test can only be covered for certain diagnoses. Therefore, we decided that the Plan has to pay 
for the COVID-19 test provided to the enrollee on June 12, 2020.  
 
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve CT of the face (70486). 
 
You asked the Plan to pre-approve the CT of the face. You say that you would like reconsideration because the 
facial feminization is a medically necessary procedure The Plan denied your request. The Plan says that the CT 
Scan is being requested for a non-covered surgery. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the CT of the face. Our reviewer says 
that the CT of the face is medically reasonable and necessary. Our physician reviewer found the CT scan of the 
face is medically reasonable and necessary in every facial gender surgery case, so the bones can be evaluated 
and models created for surgical planning. 
 
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 CT of the face have been met. Therefore, we decided that the Plan has to 
pre-approve CT of the face (70486).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the right 
lower extremity (73720). 
 
You asked the Plan to pre-approve this service. You say that an MRI of the right lower extremity is medically 
necessary as the enrollee has pain in his right foot. The Plan denied your request. The Plan says the enrollee 
does not meet criteria for coverage of an MRI of the right lower extremity. 
 
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 this service. Our reviewer says that an 
MRI of the right lower extremity is not medically necessary. Our physician reviewer found that the enrollee 
does not meet criteria for coverage as no time has passed, in the documentation provided, that suggests time 
course of pain or any attempt for conservative therapy. There was no documentation of ongoing symptoms 
and/or failed conservative management. Therefore, an MRI of the right lower extremity is not 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the magnetic resonance imaging (MRI) of the right lower extremity (73720).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist. You asked 
the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. 
The Plan says there are several in-network cardiologists who can give a second opinion. 
 
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 
a referral to an out-of-network cardiologist.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient lab work provided by a 
participating provider on May 26, 2020. 
 
You asked the Plan to waive the copayment for lab work. You say that you have never had to pay for this 
before. The Plan denied your request. The Plan says the correct copayment 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 $5 
copayment for outpatient diagnostic tests/laboratory tests.  
 
You have been asked to pay a $5 copayment for lab work. The correct copayment has been applied to the lab 
work that was provided. Lab work falls within the outpatient diagnostic tests/laboratory tests 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 copayment for outpatient lab work provided by a participating provider on 
May 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for post stabilization care provided on March 15, 2020, through 
March 16, 2020. 
 
You asked the Plan to pay for the post stabilization care. You say that you would like reconsideration because 
the services rendered were medically necessary. The Plan denied your request. The Plan says the enrollee was 
stable and able to be transferred to a Plan facility.  
 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for 
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, 
approval is required.  
 
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 post stabilization care. Our reviewer says 
that the enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport with 
monitoring to a Plan facility for observation/admission services after the emergency room evaluation on March 
15, 2020. Our physician reviewer found all inpatient care provided after 10:15pm on March 15, 2020 through 
discharge on March 16, 2020 was not medically necessary or reasonable. 
 
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 post stabilization care have not been met. Therefore, we decided that the 
Plan does not have to pay for post stabilization care provided on March 15, 2020, through March 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you do not 
have acute symptoms that require 24-hour care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
Continued services beyond November 5, 2020, were requested. 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 continued services. Our physician reviewer found that active treatment was not taking 
place. The services were not reasonably expected or medically necessary to improve your condition, or for the 
purpose of diagnosis. The services were supervised and evaluated by a physician. Based upon review the 
records, your care could be treated in a lesser restrictive setting as you were not showing any suicidal or 
homicidal ideation, auditory or visual hallucinations, delusions. You were not showing any behaviors or 
aggression, and not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for naturopath services provided from January 13, 2020, through 
April 1, 2020. 
 
You asked the Plan to pay for the naturopath services. The Plan denied your request. The Plan says naturopath 
services (uses natural or alternative treatments) are not covered under any condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopath services. The 
contract with the Plan says that naturopath services (uses natural or alternative treatments) are not covered 
under any condition. 
 
The services at issue in this appeal are naturopathic services. Medicare does not cover naturopathic services. 
The Plan does not cover naturopath services. Therefore, we decided that the Plan does not have to pay for 
naturopath services provided from January 13, 2020, through April 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation. 
 
You asked the Plan to pre-approve gingival irrigation. The Plan denied your request. The Plan says the service 
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 
gingival irrigation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient surgery you had on May 22, 
2020. 
 
You asked the Plan to waive the copayment for the outpatient surgery. You say that you will not pay this 
copayment because your condition is worse now than before. The Plan denied your request. The Plan says you 
were charged this copayment 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 a $295 
copayment for outpatient surgery.  
 
You have been asked to pay a $295 copayment for the outpatient surgery. This copayment applies regardless of 
the outcome of your procedure. 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 outpatient surgery you 
had on May 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nurtec ODT Tablet. 
 
You asked the Plan to pre-approve Nurtec ODT Tablet (J8499). You say that you want the enrollee treated with 
this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's 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 Nurtec ODT Tablet.  
 
Benefits for Nurtec ODT Tablet (J8499) 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental item. You say that you received temporary dentures before your 
teeth were removed. You say that you had 15 teeth removed and so a proper fitting could not be done. You say 
that the dentist office billed the temporary dentures as permanent ones. You also say that you were advised that 
the dentures would be covered. The Plan denied your request. The Plan says dentures are covered once every 
60 months. The Plan also says that the frequency limit has been reached. 
 
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 frequency limit of 1 denture every 
60 months has been reached. The record shows that you received a lower denture on August 23, 2019. 
Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 extractions (D7140) and a lower denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you had 2 teeth break off. You say that 
they are black now. You say that you are on a very limited income and cannot afford to pay for the extractions 
that you need. The Plan denied your request. The Plan says extractions are not listed as a covered service. The 
Plan says that the denture is not a listed as a covered service either. 
 
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 8 
extractions (D7140) and a lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) and 
the periodontal maintenance (D4910). 
 
You asked the Plan to pre-approve the dental services. You say that you are on a fixed income. You also say 
that you cannot get on a payment plan. The Plan denied your request. The Plan says there is a maximum plan 
benefit of $750 per year for preventive and comprehensive dental services. The Plan says that the maximum 
benefit has been exhausted. 
 
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 maximum benefit of $750 per year 
has been exhausted. 
 
Date of Service Claim # Plan Paid 
2/6/2020 58785848 $145 
2/6/2020 58786260 $87 
8/13/2020 59155837 $122 
8/31/2020 59250316 $87 
9/14/2020 59284199 $30 
 59290445 $279 
TOTAL:  $750 
 
 
 
 
The record shows that the Plan fully approved scaling and root planing for the upper left, upper right, and lower 
left quadrants and partially approved the lower right quadrant, thus exhausting the maximum benefit. 
Therefore, we decided that the Plan does not have to pre-approve the periodontal scaling and root planing 
(D4341) and the periodontal maintenance (D4910).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve RYBO Air Balance Braces. 
 
You asked the Plan to pre-approve the RYBO Air Balance Braces. You say that you would like reconsideration 
because this equipment is medically necessary. The Plan denied your request. The Plan says that there is a lack 
of objective physical exam findings and the lack of a trial with a prefabricated ankle foot orthosis. 
 
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 the RYBO Air Balance Braces. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found documentation in the case file supports that the enrollee has weakness or 
deformity of the foot and ankle, requires stabilization for medical reasons, and has the potential to benefit 
functionally. 
 
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 RYBO Air Balance Braces have been met. Therefore, we decided that the 
Plan has to pre-approve RYBO Air Balance Braces.  
 
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.