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

We decided that the Plan has to pre-approve periodontal scaling and root planing in the upper quadrants. You asked the Plan to pre-approve periodontal scaling and root planing in the upper quadrants. You say that root planing and scaling is needed due to interproximal pockets greater than 4 mm and acute inflammation. The Plan denied your request. The Plan says that the criteria for coverage has not been met.

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 periodontal scaling and root planing in the upper quadrants when the services are medically necessary and reasonable.

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 periodontal scaling and root planing in the upper quadrants. Our physician reviewer found that the radiographs indicate the presence of abnormal periodontal pocketing greater than 4mm and bone loss in the four quadrants. Our reviewer says that due to the abnormal periodontal pockets and bone loss, the criteria for coverage for scaling and root planing have been met.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal scaling and root planing in the upper quadrants have been met. Therefore, we decided that the Plan has to pre-approve periodontal scaling and root planing in the upper quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (D7953). 
 
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says bone graft 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. Therefore, we decided that the Plan does not have to pre-approve a 
bone graft (D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wheelchair cushion. 
 
You asked the Plan to pre-approve the cushion. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not currently have a 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 cushion. Our reviewer says that the 
requested cushion is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that the enrollee has a covered wheelchair with a sling/solid seat back. 
 
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 cushion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a wheelchair cushion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a plug-in TENS unit. 
 
You asked the Plan to pre-approve the unit. You say that you are trying to avoid having surgery. The Plan 
denied your request. The Plan says the vendor can fix the current unit. 
 
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 unit. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a request has been made for a new device which would serve the same clinical purpose--the only 
difference being the manner in which the device receives power. You are noted to already have a TENS for the 
management of your shoulder pain. The requested device would therefore not be considered to be reasonable 
and necessary as you already have equipment that serves the same purpose. This request is more for your 
convenience. 
 
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 unit have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a plug-in TENS unit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns for teeth #s 8 and 9. 
 
You asked the Plan to pre-approve the crowns for teeth #s 8 and 9. The Plan denied your request. The Plan says 
this service is not medically necessary. 
 
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. The Plan covers the crowns 
for teeth #s 8 and 9 when the services are medically necessary and reasonable.  
 
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 crowns for teeth #s 8 and 9. Our 
reviewer says that the criteria for coverage has not been met. Our physician reviewer found that the amount of 
damage to either tooth is less than 50% and neither has involvement of the incisal edges. Our reviewer says that 
given the criteria of the Plan, and the presentation of the teeth from the provided documentation, the criteria has 
not been met and there is no necessity for the requested procedures. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns for teeth #s 8 and 9 have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the crowns for teeth #s 8 and 9.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergent transportation. 
 
You asked the Plan to pre-approve non-emergent transportation. You say that you are requesting transportation 
to see your doctor since you have a lot of back pain. The Plan denied your request. The Plan says transportation 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. 
The Plan follows the same rule.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Medicare rules for coverage of non-emergent transportation have not been met. Transportation services 
are not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve non-emergent 
transportation.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Invitae Pulmonary Arterial Hypertension Panel for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says it does not appear that the results of genetic testing will directly impact or change 
clinical management of the enrollee's condition. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is noted to have pulmonary hypertension and morbid obesity, for which she takes Viagra and 
inconsistently uses NiPPV. There is no indication of how genetic testing would affect her diagnosis or 
treatment. As such, the requested test is not shown to be 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Invitae Pulmonary Arterial Hypertension Panel for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the new patient office or other outpatient visit to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the new patient office or other outpatient visit. You say that you would like 
to see this OON provider because you have family in the area. The Plan denied your request. The Plan says the 
service can be provided by an in-network provider and is non-emergent. 
 
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 new patient office or other outpatient visit to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that it is hard for you to go up and down the stairs to 
your shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a one month rental of a Negative Pressure Wound Therapy (NPWT) device and supplies (A6550, A7000, E2402).

You asked the Plan to pre-approve the Negative Pressure Wound Therapy (NPWT) device and supplies. You say that the additional month rental of the NPWT device is medically necessary. The Plan denied your request. The Plan says coverage criteria is no longer met.

The Plan must follow Medicare rules. Medicare rules say that Negative Pressure Wound Therapy devices are not covered when 4 months have elapsed using an NPWT pump in the treatment of the most recent wound. 

We looked at the file and Medicare rules. The record shows the device has already been used for greater than 4 months on the most recent wound. Based on this information, we decided that Medicare rules for coverage of the Negative Pressure Wound Therapy (NPWT) device and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a one month rental of a Negative Pressure Wound Therapy (NPWT) device and supplies (A6550, A7000, E2402).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). You say that the tooth has a large existing restoration 
that is leaking and a fracture on the distal ridge. You say that core buildup and a full coverage crown is proper 
restoration. 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 core 
buildup (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repair of power wheelchair and accessories for the 
enrollee. 
 
You asked the Plan to pre-approve the repair. You say that this is medically necessary. The Plan denied your 
request. The Plan says this power wheelchair is not cost effective to repair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 repair. Our reviewer says that the 
requested repair is not medically reasonable or necessary. Our physician reviewer found this is not medically 
necessary without clear details of the enrollee's wheelchair. 
 
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 repair have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a repair of power wheelchair and accessories for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intravenous conscious sedation, initial 15 minutes 
(D9239), and intravenous conscious sedation, additional 15 minutes (D9243). 
 
You asked the Plan to pre-approve the dental services. You say that you have an impacted tooth that needs to 
be removed. You also say that you have multiple health issues and therefore need the sedation. The Plan denied 
your request. The Plan says intravenous conscious sedation is not 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 pre-approve 
intravenous conscious sedation, initial 15 minutes (D9239), and intravenous conscious sedation, additional 15 
minutes (D9243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea porcelain fused to noble metal crown (D2752).You asked the Plan to pre-approvethe dental service. The Plan denied your request. The Plan says crowns are 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. The Evidence of Coverage specifically states that bridges andcrowns are not covered.Therefore, we decided that the Plan does not have to pre-approvea porcelain fused to noble metal crown (D2752)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cryoneurolysis of the peripheral nerves of the knee for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is still being studied to determine safety and efficacy. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is still considered an experimental/investigational procedure that is the subject of ongoing clinical 
trials. Therefore, the request is deemed 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cryoneurolysis of the peripheral nerves of the knee for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cold pad with pump (E0218). 
 
You asked the Plan to pre-approve the cold pad.. You say that the cooling pad with pump is medically 
necessary. The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) 
will be denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Medicare rules say this device is not considered medically necessary 
and is non-covered. Based on this information, we decided that Medicare rules for coverage of the cold pad. 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a cold pad with pump 
(E0218).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on 
June 24, 2020. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you went to several different 
hospitals and no one was able to treat you properly.  You say that you should not have to pay this copayment. 
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 $90 
copayment for emergency room services.  
 
You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason 
for the ER visit. 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 emergency room (ER) visit 
you had on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a duplex scan provided on June 11, 2020.You asked the Plan to pay for the duplex scan. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would requirethe Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a duplex scan provided on June 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing and periodontal 
maintenance provided on May 13, 2020. 
 
You asked the Plan to pay for periodontal scaling and root planing and periodontal maintenance. You say that 
you are entitled to a deeper periodontal cleaning and overall maintenance cleaning twice per year. The Plan 
denied your request. The Plan says the services are not covered benefits. 
 
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 pay for 
periodontal scaling and root planing and periodontal maintenance provided on May 13, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on January 
21, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you keep getting bills with 
different amounts and cannot afford the charges. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $270 
copayment for ambulance services.  
 
You have been asked to pay a $270 copayment for ambulance services. Ambulance services fall within the 
ambulance services 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 ambulance services 
provided on January 21, 2020.