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

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you need this to help you get 
into your wheelchair. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered 
because it is not primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested item is non-covered under 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 (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that you have a sensitive digestive system 
and you need to see this provider for an elemental diet. The Plan denied your request. The Plan says you do not 
meet the Plan's guidelines to see a provider that is out-of-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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left shoe 2 inch build up. 
 
You asked the Plan to pre-approve foot orthotics. You say that your doctor ordered a left show 2 inch build up. 
Contrary to the description of the denial the lift is being built into the shoe. It is a custom built shoe and not just 
a lift that would be inserted. 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 a left shoe 2 inch build up.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by an OON provider. 
 
You asked the Plan to pre-approve dental services. You say that you need these services due to a history of 
dental problems. The Plan denied your request. The Plan says there are providers in your area who can provide 
your care. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve dental 
services to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the chest 
(71552). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found there is no specific clinical rationale for the 
requested MRI of the chest. This test is medically necessary if an x-ray shows that the ribs, shoulder bones, or 
chest wall are not normal or that there is a growth in your chest wall. There is no x-ray to support medical 
necessity of the MRI. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Magnetic Resonance Imaging (MRI) of the chest (71552).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a POV (K0801). 
 
You asked the Plan to pay for the POV. You say that you would like reconsideration because you get dizzy and 
often fall. The Plan denied your request. The Plan says the medical records failed to document that your 
condition can no tbe ameliorated by a walker, cane or manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that if a POV will be used inside the home and coverage 
criteria criteria are not met, it will be denied as not 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 pay for the POV. Our reviewer says that the 
documentation does not clearly reveal why the mobility limitation cannot be overcome by an appropriately 
fitted walker or manual wheelchair. Our physician reviewer found the physician's progress note indicate the 
patient has normal power in his extremities. There is no detailed neuromuscular exam in the submitted 
documentation. 
 
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 POV have not been met. Therefore, we decided that the Plan does not have 
to pay for a POV (K0801).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that you have treated the member in the 
past for bilateral hip and knee pain and her x-rays showed mild arthritis. You say that in your medical opinion, 
the members arthritis may be worse. The Plan denied your request. The Plan says the enrollee must receive 
care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out 
of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior 
authorization from the plan. 
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
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. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 chronic obstructive 
pulmonary disease (COPD) with hospitalizations for acute on chronic hypercarbic respiratory failure. Failure of 
BiPAP has not been demonstrated at home. Medicare does not cover a home ventilator when used as BiPAP. 
The home ventilator is not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a massage chair. 
 
You asked the Plan to pre-approve these services. You say that you are in a lot of pain and get muscle spasms. 
The Plan denied your request. The Plan says the item is 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-approve a massage chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a POV (K0800). 
 
You asked the Plan to pre-approve the POV. You say that you would like reconsideration because this 
equipment is medically necessary. The Plan denied your request. The Plan says the records do not show that 
you are unable to use a walker, cane or manual wheelchair. 
 
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 POV. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you are not noted to have the inability to utilize a lesser device (lightweight manual wheelchair, 
for example). 
 
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 POV have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a POV (K0800).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation. 
 
You asked the Plan to pre-approve the comprehensive oral evaluation. You say that you would like this service 
in order to maintain your hygiene because of your condition. The Plan denied your request. The Plan says this 
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, comprehensive oral exams are limited 
to one procedure every three years. The record shows that you received a comprehensive oral evaluation on 
May 21, 2019 and your comprehensive oral exams benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pre-approve a comprehensive oral evaluation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pacemaker insertion. 
 
You asked the Plan to pre-approve pacemaker insertion. The Plan denied your request. The Plan says this is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a pacemaker is covered for the above indications. 
 
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 pacemaker insertion. Our reviewer says 
that the requested pacemaker is not medically reasonable and necessary. Our physician reviewer found that the 
enrollee has sinus bradycardia while on metoprolol that may be reversible to some extent after discontinuation 
of that medication. Also, there are no documented symptoms of hypotension, presyncope or syncope. Fatigue is 
very nonspecific and may not be related to sinus bradycardia especially if there is a normal chronotropic 
response to exercise. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pacemaker insertion have not been met. Therefore, we decided that the Plan 
does not have to pre-approve pacemaker insertion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continuous glucose monitor, Freestyle Libre 14 day 
sensor and reader. 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the records should support the 
necessity of the services in dispute. The Plan denied your request. The Plan says the continuous glucose 
monitoring is not medically necessary for this enrollee. 
 
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 continuous glucose monitor. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found it does not demonstrate from records that patient is on insulin.  Does not 
qualify for Freestyle Libre based on not being on insulin, not being on multidose insulin, and not checking 
blood sugar at high enough frequency 
 
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 continuous glucose monitor have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the continuous glucose monitor, Freestyle Libre 14 day sensor and 
reader.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Chelation Therapy. 
 
You asked the Plan to pre-approve Chelation Therapy. You say that you need this treatment. The Plan denied 
your request. The Plan says studies have not proven that this procedure is helpful for treatment without signs or 
symptoms of heavy metal poisoning or history of exposure. 
 
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 Chelation Therapy. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found blood testing indicates normal levels of all heavy metals. Whole blood testing of heavy metals 
is considered the most accurate method of determining heavy metal toxicity. Per review of the peer reviewed 
medical literature, chelation therapy is an established treatment for heavy metal poisoning. There is no 
evidence of effectiveness of chelation therapy in the setting of normal blood levels of heavy metals. In this 
case, the enrollee does not have a diagnosis that meets criteria for chelation therapy. The requested chelation 
therapy at issue in this case 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 Chelation Therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Chelation Therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is 
not covered under the enrollee's dental plan. 
 
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 a 
core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service 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 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 a 
core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant/abutment supported interim fixed 
mandibular denture for edentulous arch. 
 
You asked the Plan to pre-approve the implant/abutment supported interim fixed mandibular denture for 
edentulous arch. You say that you need the implant so you can eat. The Plan denied your request. The Plan says 
this service is not covered under your benefit plan. 
 
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 an 
implant/abutment supported interim fixed mandibular denture for edentulous arch.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an addition of tooth to an existing partial denture. 
 
You asked the Plan to pre-approve the addition of tooth to an existing partial denture. The Plan denied your 
request. The Plan says this service is not covered under your benefit plan. 
 
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 an 
addition of tooth to an existing partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wound vac (A7000, A6550, E2402) to be provided 
by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the wound vac. You say that the wound vac is medically necessary. The 
Plan denied your request. The Plan says there are network providers available. 
 
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 wound vac (A7000, A6550, E2402) 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 two custom fabricated abutments (D6057 x2) and two 
implant supported crowns (D6066 x2). 
 
You asked the Plan to pre-approve the custom fabricated abutments and implant supported crowns. You say 
that these services need to be provided otherwise the implant will experience bone loss, pain and infection over 
time. The Plan denied your request. The Plan says these services are not covered under the enrollee's benefit 
package. 
 
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 two 
custom fabricated abutments (D6057 x2) and two implant supported crowns (D6066 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two treatments of root canal obstructions (D3331 x2). 
 
You asked the Plan to pre-approve the treatments of root canal obstructions. You say that you say that your 
teeth are calcified and causing obstruction. The Plan denied your request. The Plan says this service is not 
covered under your benefit package. 
 
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 
treatments of root canal obstructions (D3331 x2).