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

 
We decided that the Plan does not have to pre-approve backrest angle adjustable with push handle (wheelchair 
component or accessory, not otherwise specified (K0108)), for the enrollee. 
 
You asked the Plan to pre-approve the item. You say that you are requesting review of denial of services. The 
Plan denied your request. The Plan says this is a non-standard upgrade and does not primarily serve a medical 
purpose. 
 
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 backrest angle adjustable with push handle (wheelchair 
component or accessory, not otherwise specified (K0108)), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testosterone Cypionate. 
 
You asked the Plan to pre-approve the Testosterone Cypionate. You say that the enrollee has been on 
Testosterone Cypionate for over 10 years now, to help with his Testicular Hypofunction, which he has 
benefited from. 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 Testosterone Cypionate.  
 
Benefits for the Testosterone Cypionate 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep apnea oral appliance (E1399). 
 
You asked the Plan to pre-approve the oral appliance. You say that you need the oral appliance to treat your 
obstructive sleep apnea. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that oral appliances for treatment of sleep apnea are 
covered when medically necessary, particularly when a CPAP machine is contraindicated or not tolerated. 
 
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 oral appliane. Our reviewer says 
that the oral appliance is not medically necessary. Our physician reviewer found there is no documentation that 
the CPAP machine the enrollee is using is not effective in treating her sleep apnea. The oral appliance is not 
medically necessary in this case. 
 
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 oral appliance have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sleep apnea oral appliance (E1399).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve PET scan with concurrently acquired computed 
tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh (CPT 
Code 78815), for the enrollee. 
 
You asked the Plan to pre-approve the PET scan. You say that the imaging is medically necessary. The Plan 
denied your request. The Plan says the imaging is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PET scan. Our physician reviewer 
found the following review of the clinical documentation provided, the review has determined that Prostate 
cancer does not meet MCG criteria per Tumor Imaging Positron Emission Tomography (PET) and PET-CT. 
The review has determined that the member does not have an indication for which a PET Scan can be covered 
at this time. The requested PET scan is not medically necessary or reasonable for the enrollee 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve PET scan with concurrently acquired computed tomography (CT) for attenuation 
correction and anatomical localization imaging; skull base to mid-thigh (CPT Code 78815), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy of a lower extremity vein. 
 
You asked the Plan to pre-approve endovenous ablation therapy. You say that the enrollee has failed 
conservative treatment and is a candidate for ablation therapy. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because the enrollee does not meet the Medicare criteria for 
coverage. 
 
The Plan follows Medicare rules. Medicare rules say that endovenous ablation therapy may be covered as 
medically necessary when certain clinical criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve endovenous ablation therapy. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested endovenous ablation 
therapy. Our physician reviewer found coverage requires that the enrollee's symptoms be due to her varicose 
veins.  
 
The enrollee has severe pain when her legs are elevated at night and she cannot tolerate sheets being on her 
feet. This is inconsistent with varicose vein symptoms. Furthermore, the degree of reflux in the greater 
saphenous veins bilaterally is modest at best. Inability to tolerate compression stockings further suggests that 
alternative etiologies for her leg pain be investigated. 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve endovenous ablation therapy of a lower extremity vein.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Denosumab (Prolia). 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee has not had a hip or vertebral fragility 
fracture. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary for the enrollee. Our physician reviewer found the enrollee has 
osteopenia by Dexa scan. Our reviewer also found that the documentation does not support that the Prolia 
(J0897) is safe and effective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Denosumab (Prolia).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve the periodontal scaling and root planing in all four quadrants. We 
decided that the Plan does not have to pre-approve the surgical extraction.  
 
You asked the Plan to pre-approve the extraction and periodontal scaling and root planing. The Plan says the 
criteria for coverage has not been met. 
 
  
We decided that the Plan has to pre-approve the periodontal scaling and root planing in all four 
quadrants.  
 
Our physician reviewer says that the criteria for coverage has been met. Our physician reviewer found that 
there are 5mm periodontal pockets around teeth in all four quadrants and presence of subgingival calculus. 
Therefore, we decided that the Plan has to pre-approve the periodontal scaling and root planing.  
 
We also decided that the Plan does not have to pre-approve the extraction. 
 
Our physician reviewer found that the roots are partially resorbed and not encased in bone. Our reviewer says 
that an extraction via elevation and or forceps would be adequate. Therefore, we decided that the Plan does not 
have to pre-approve a surgical extraction. 
 
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 pre-approve thirteen endosteal implants (D6010 x13). 
 
You asked the Plan to pre-approve the endosteal implants. You say that these services are medically necessary. 
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 
thirteen endosteal implants (D6010 x13).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve migraine surgery. 
 
You asked the Plan to pre-approve the surgery. You say that you would like reconsideration because this 
surgery is medically necessary. The Plan denied your request. The Plan says this service is considered 
experimental/investigational. 
 
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 surgery. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not include documentation of reproducible trigger points or temporary response 
of trigger points to other treatments, such as botulinum toxin. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve migraine surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve 15 office consultations and treatment with an out-of-network neurologist. 
You say that you want continued services with your neurologist. The Plan denied your request. The Plan says 
you have been redirected to an in-network provider. 
 
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 
medical services to be provided by an out-of-network provider.
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. The Plan denied your request. The Plan says except 
in emergencies, certain urgently needed services, out of the area dialysis services, and when the providers in 
our network cannot provide your care, you must use plan providers in order for services to be covered. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture and a mandibular partial 
denture. 
 
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that 
you are unable to eat because you have no teeth. The Plan denied your request. The Plan says these services are 
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 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 
maxillary partial denture and a mandibular partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre 14 day sensors. 
 
You asked the Plan to pre-approve Freestyle Libre 14 day sensors. You say that this is medically necessary. 
The Plan denied your request. The Plan says that your provided did not submit documentation that you meet 
criteria for coverage. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that therapeutic 
CGMs are covered when the above criteria have been met. Medicare rules also say that information must be 
submitted to confirm that Medicare coverage criteria have been met. 
 
We looked at the file and Medicare rules. The case file did not include medical records. The case file shows 
that the Plan sent notification that this medical documentation was needed. Without medical records, we cannot 
make a determination regarding medical necessity and you have not proven that Medicare coverage criteria for 
Freestyle Libre 14 day sensors have been met. Based on this information, we decided that Medicare rules for 
coverage of Freestyle Libre 14 day sensors have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Freestyle Libre 14 day sensors.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee could have another heart attack or stoke. 
The Plan denied your request. The Plan says the services could be safely received in another setting. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
acute MI and had coronary artery bypass grafting. Medical problems are stable. There are no complex nursing 
or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the record supports a need for 
physical and occupational therapy, there is no documented need for an intensive rehabilitation program. There 
is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopy procedure. 
 
You asked the Plan to pre-approve a laparoscopy procedure (58661). You say that you are requesting an 
exception to the ruling on sterilization. The Plan denied your request. The Plan says this procedure is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a laparoscopy procedure (58661) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a laparoscopy procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say 
that you received dentures and 5 teeth fell out of one of them, and the other never fit correctly. You also say 
that you have not been able to get them fixed due to the closures. The Plan denied your request. The Plan says 
these services exceed the maximum count allowed per period. 
 
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, complete maxillary denture (D5110) 
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record 
shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on 
November 11, 2019, and your complete dentures benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture 
(D5120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the record does not show that the enrollee 
had a failed trial of the plan preferred drugs. The record does not show any reason the plan preferred drugs 
would be unsafe or ineffective for 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee is receiving appropriate care at the current acute care 
facility. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient still requires an acute level of medical 
care and is not able to participate in intensive rehabilitation services at this time. The patient require does not 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the record supports a need for physical and occupational therapy, there is 
no documented need for an intensive rehabilitation program and the patient is unable to participate in such a 
program given the acuity of medical problems. Our physician reviewer found that the enrollee's condition does 
not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.