Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement. 
 
You asked the Plan to pre-approve the spacer placement. You say that the services requested are 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 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 spacer placement. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested spacer device is experimental. More research is needed to show safety 
and efficacy. 
 
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 spacer placement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an interspinous spacer placement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high gold content crown (D2790) for tooth # 20. 
 
You asked the Plan to pre-approve the crown for tooth # 20. You say that you need these services to be 
approved. You also say that you cannot afford to pay for these services on your own. The Plan denied your 
request. The Plan says crowns are covered once per tooth every 5 years. The Plan also says that the frequency 
limit for this service 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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and crowns are a covered service, the 
frequency limit has been reached. The record shows that you received a crown for tooth # 20 on May 9, 2016, 
less than 5 years ago. Therefore, we decided that the Plan does not have to pre-approve a high gold content 
crown (D2790) for tooth # 20.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelumbar epidural steroid injections.You asked the Plan to pre-approvelumbar epidural steroid injections. The Plan denied your request. The Plan says the injections are not medically necessary.The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are 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 lumbar epidural steroid injections. Our reviewer says that the requested injections are not medically reasonable and necessary. Our physician reviewer found that the enrollee has not had a failure of four weeks (from onset of pain) of non-surgical, non-injection care, which includes appropriate oral medication and physical therapy to the extent tolerated. The requested injections are not medically reasonable or necessary according to the coverage criteria established in the above LCD.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar epidural steroid injections have not been met.Therefore, we decided that the Plan does not have to pre-approvelumbar epidural steroid injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction (D7210) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve the dental service. You say that your dentist advised that you need your 
tooth extracted. You say that your dentist also advised that they do not perform extractions. You also say that 
you never use your insurance or take medications so you do not understand why the services you need are not 
covered. The Plan denied your request. The Plan says dental services provided by an oral surgeon are not 
covered. The Plan also says that dental services must be provided by a participating general dentist. 
 
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, dental services are only covered when 
you receive them from a participating general dentist. Therefore, we decided that the Plan does not have to pre-
approve an extraction (D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to upcoming surgeries. The Plan denied your request. The Plan says that you have exhausted the benefit. 
 
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 a maximum of fifty (50) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that for claims with dates of service on or after 
January 9, 2014, PILD, procedure code 0275T, is a covered service only when billed as part of a clinical trial. 
 
We looked at the file and Medicare rules. The requested services are only covered when billed as part of a 
clinical trial. The clinical trial for this procedure is available for enrollment and payment for Medicare 
Advantage beneficiaries. Based on this information, we decided that Medicare rules for coverage of the 
procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous 
image-guided lumbar decompression.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you are post-op and suffering. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal spacer. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of back pain. 
The requested spinal spacer is considered experimental in nature, as more research is needed to show safety 
and efficacy. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CardioMEMS. 
 
You asked the Plan to pre-approve implantation of hemodynamic monitor (33289). You say that a doctor can 
use the information from this device to adjust medications and treatment plans. The Plan denied your request. 
The Plan says CardioMEMS is experimental and 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 implantation of hemodynamic monitor 
(33289). Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this circumstance therapy change based on data 
obtained from a CardioMEMs device has been demonstrated in only one trial to help reduce hospital 
readmission compared to standard medical therapy. The efficacy of the CardioMEMS device is uncertain at 
this time according to leading authorities and not recommended in current guidelines for the treatment of heart 
failure. Medicare coverage criteria are not met, since the device should still be considered experimental or 
investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantation of hemodynamic monitor (33289) have not been met. Therefore, 
we decided that the Plan does not have to pre-approve CardioMEMS.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to approve two additional routine transports. 
 
You asked the Plan to approve these services. You say that you do not have a way to get to your appointment. 
The Plan denied your request. The Plan says you have exhausted the benefit limit. 
 
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 a maximum of 10 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to approve two additional routine transports.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services to be provided by out-of-network 
provider. 
 
You asked the Plan to pre-approve the physician's services. You say that you do not want to return to the in-
network hematologist that you had a consult with last month as you had a long wait time and the office was 
cramped and the office staff were very unprofessional. You say that you need to stay with this physician for 
continuity of care since this physician is already familiar with your condition and manages your condition. The 
Plan denied your request. The Plan says the service is available within the primary network and your condition 
is not an emergency. 
 
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 and accessible 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 physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve supplies for a Dexcom G6 continuous glucose monitor 
(CGM) (K0553). 
 
You asked the Plan to pre-approve the CGM supplies. You say that the supplies are medically necessary. The 
Plan denied your request. The Plan says the documentation does not show that the enrollee has tried the plan 
preferred brand of Continuous Glucose Monitor and supplies. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers.  
 
 
 
We looked at the file and Medicare rules. In this case, the plan contract states that the preferred brand of 
CGM's is Freestyle. The Record shows no trial of the plan preferred CGM and supplies. No medical records 
were provided to show why the plan preferred brand would be unsafe or ineffective for the enrollee. Based on 
this information, we decided that Medicare rules for coverage of the CGM supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve supplies for a Dexcom G6 continuous 
glucose monitor (CGM) (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmological services to be provided by the out-of-
network provider. 
 
You asked the Plan to pre-approve the ophthalmological services. The Plan denied your request. The Plan says 
the Plan does not cover non-emergency services by a non-contracted provider when a contracted provider can 
do the services. 
 
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 
ophthalmological services to be provided by the out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete upper dentures (D5110) and complete lower 
dentures (D5120). 
 
You asked the Plan to pre-approve complete upper dentures and complete lower dentures. You say that the 
items are necessary. The Plan denied your request. The Plan says the 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. The Plan covers complete 
dentures (upper and lower) once every five years. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of complete upper dentures and complete lower dentures have not been met. The plan covers 
complete upper dentures and complete lower dentures once every five years. The record shows that you 
received complete upper dentures and complete lower dentures on August 2, 2019. This means that you are not 
eligible for health plan coverage of complete upper dentures and complete lower dentures at this time. 
Therefore, we decided that the Plan does not have to pre-approve complete upper dentures (D5110) and 
complete lower dentures (D5120).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-emergent ambulance transport (A0428). 
 
You asked the Plan to pre-approve the non-emergency ambulance transport. You say that the ambulance 
service is medically necessary. The Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance transportation is covered only when 
transportation by any other means of transportation is contraindicated by the medical condition of the 
beneficiary.  
 
We looked at the file and Medicare rules. In this case, insufficient medical records were provided to show that 
the enrollee is unable to be transported by other means. Based on this information, we decided that Medicare 
rules for coverage of the non-emergency ambulance transport have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a non-emergent ambulance transport (A0428).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that this is needed to help the pain in your lower 
back. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair 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 shower chair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CTA of the chest. 
 
You asked the Plan to pre-approve a CTA. You say that the enrollee wants a CTA earlier than scheduled, 
before traveling. The Plan denied your request. The Plan says personal travel does not establish medical 
necessity for early testing. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We looked at the file and Medicare rules. It is not medically necessary to have the CTA early because of 
personal travel. Based on this information, we decided that Medicare rules for coverage of a CTA have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography 
angiography of the chest.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant (D6010). 
 
You asked the Plan to pre-approve the dental service. You say that you had 5 teeth pulled. You say that the 
dentist advised you need an implant to correct the problem in your mouth. You also say that you do not have 
the income to pay for dental implants. The Plan denied your request. The Plan says the implant 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 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. Additionally, the services you are asking the Plan to pre-approve 
involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting 
your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that 
the Plan does not have to pre-approve the implant (D6010).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone grafting for the upper and lower jaws, 
endosteal implants, alveoloplasty, oral surgical splint, and an obturator prostheses. 
 
You asked the Plan to pre-approve the dental services. You say that the requested services are medically 
necessary. You also say that the enrollee suffers from jaw pain, inflammation, and the inability to chew 
properly. The Plan denied your request. The Plan says the requested services are part of the process of 
replacing your missing teeth with implants. The Plan also says that the requested services are not covered under 
your medical insurance in this situation. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
Although you have dental coverage beyond Medicare, you have requested the services be covered under your 
medical plan. The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal 
or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental 
services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-
approve the bone grafting for the upper and lower jaws, endosteal implants, alveoloplasty, oral surgical splint, 
and an obturator prostheses.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implant supported prosthesis repair. 
 
You asked the Plan to pre-approve the implant supported prosthesis repair. You say that the prosthesis over the 
implant wore off and fell. You say that you cannot afford another prosthesis. 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 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 the 
implant supported prosthesis repair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle test strips. 
 
You asked the Plan to pre-approve FreeStyle test strips. You say that the use of the same test strips is medically 
necessary. The Plan denied your request. The Plan says FreeStyle test strips are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred brands and may limit use to only those preferred brands.
 
 
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 FreeStyle test strips. Our reviewer says 
that the FreeStyle test strips do not meet the criteria for medical necessity. Our physician reviewer found there 
is no reason the other preferred brands cannot be used. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of FreeStyle test strips have not been met. Therefore, we decided that the Plan 
does not have to pre-approve FreeStyle test strips.