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

 
We decided that the Plan does not have to pre-approve Esomeprazole. 
 
You asked the Plan to pre-approve Esomeprazole. The Plan denied your request. The Plan says this is not 
covered under the enrollee's Part B plan. 
 
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 Esomeprazole.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive dental service (D1999) provided 
on July 20, 2020. 
 
You asked the Plan to pay for the dental service. You say that you only received a routine cleaning and x-ray. 
You say that you did not get information on what was denied. You also say that these services have been 
covered in the past. The Plan denied your request. The Plan says the unspecified preventive dental service is 
not listed as a covered service. The Plan also says any services not listed are not covered. 
 
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 clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pay for the unspecified preventive dental 
service (D1999) provided on July 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Golden Technologies GR541D electric scooter. 
 
You asked the Plan to pre-approve the Golden Technologies GR541D electric scooter.. You say that you would 
like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan 
says the documentation does not support that this equipment is for use inside the home and the record does not 
support medical necessity. 
 
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 Golden Technologies GR541D 
electric scooter. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the documentation does not support that you have a 
mobility limitation that significantly impairs your ability to participate in one or more mobility-related 
activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary 
locations in the home. 
 
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 Golden Technologies GR541D electric scooter. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Golden Technologies GR541D electric 
scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of thickening bone around teeth in the 
upper and lower arch (D7471). 
 
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says the removal 
of thickening bone around teeth in the upper and lower arch is not listed as a covered service. The Plan also 
says if a dental item or service is not listed in the benefit chart then it 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 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 the 
removal of thickening bone around teeth in the upper and lower arch (D7471).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided by a 
participating provider on July 7, 2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you did not want to go to the 
hospital. You say that the seizure had you confused. The Plan denied your request. The Plan says the correct 
copayment has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for ambulance services/ground travel.  
 
You have been asked to pay a $250 copayment for ambulance services. Since ambulance services were 
provided, the correct copayment has been applied. Ambulance services fall within the ambulance 
services/ground travel 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 by a participating provider on July 7, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
April 7, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you feel you should 
not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan 
denied your request. The Plan says you received emergency care services on the date of service at issue in this 
appeal. The Plan says the correct copayment has applied per your contract with the Plan. 
 
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 $120 
copayment for Emergency care.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received emergency room 
services on April 7, 2020. You have been asked to pay a $120 copayment for the emergency room services. 
The emergency room services fall within the Emergency care 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 the emergency room services provided on April 7, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lipid screening testing provided to the enrollee on March 9, 
2020. 
 
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare says tests with no relation to a medical diagnosis of disease for the health of 
the patient are not a benefit. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found no provider records have been submitted for review. Therefore, there is no evidence to support that the 
provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the 
enrollee's condition(s). In general, screening tests are permitted in limited circumstances and must be 
accompanied by proper documentation and coding. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for lipid screening testing provided to the enrollee on March 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that this should be covered. The Plan denied 
your request. The Plan says the benefit has been exhausted. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 6 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 pre-approve additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sterilization surgery. 
 
You asked the Plan to pre-approve the laparoscopic procedure. You say that it would be life threatening if you 
were to become pregnant. The Plan denied your request. The Plan says you do not meet clinical criteria for this 
procedure. 
 
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. Medicare does not cover this procedure when preventative. Based on 
this information, we decided that Medicare rules for coverage of the sterilization procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a sterilization surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a foam pillow and a cushion. 
 
You asked the Plan to pre-approve a foam pillow and a cushion. You say that your neck and knees hurt when 
you sleep. The Plan denied your request. The Plan says these items are not used primarily for health related 
reasons. 
 
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. These items are 
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 foam pillow and a cushion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual wheelchair IV hanger or transit option. 
 
You asked the Plan to pre-approve a manual wheelchair IV hanger or transit option. You say that the enrollee 
needs a manual wheelchair with tilt in space, IV hanger and transit option. The Plan denied your request. The 
Plan says the IV hanger is not considered medical in nature and transit option is a convenience item not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. These items are 
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 manual wheelchair IV hanger or transit option.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty, extra-wide hospital bed. 
 
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered 
for patients between 350 and 600 pounds.  
 
The enrollee's weight is 183 pounds. This is not within the covered range for the requested bed. Based on this 
information, we decided that Medicare rules for coverage of the bed have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a heavy-duty, extra-wide hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a manual fully reclining back option. 
 
You asked the Plan to pre-approve a manual fully reclining back option. You say that this is medically 
necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. A manual fully reclining back option (E1226) is covered if the 
beneficiary has one or more of the following conditions: The beneficiary is at high risk for development of a 
pressure ulcer and is unable to perform a functional weight shift; or utilizes intermittent catheterization for 
bladder management and is unable to independently transfer from the wheelchair to the bed. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a manual fully reclining back option have not been met. The item at issue is not being ordered for 
one of the conditions that are covered by Medicare. Therefore, we decided that the Plan does not have to pre-
approve a manual fully reclining back option.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950). 
 
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says core build 
up is not listed as a covered service. The Plan also says if a dental item or service is not listed in the benefit 
chart or listed with NC, then it 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 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 
build up (D2950).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy visits. 
 
You asked the Plan to pre-approve 8 additional physical therapy visits. You say that you need more physical 
therapy to strengthen your knee. The Plan denied your request. The Plan says additional visits are not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 8 additional physical therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has had extensive therapy for this 
condition and should be able to transition to a home exercise program. Our reviewer says that the unique skills 
of a professional therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
2, 2019 to August 21, 2019. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this provider is not eligible for Medicare 
payment. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, this claim 
has not been submitted with an appropriate type of bill code for home health services. Therefore, we decided 
that the Plan does not have to pay for the home health services provided to the enrollee from April 2, 2019 to 
August 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says your medical 
conditions are stable, and you are unable to tolerate 3 hours of therapy a day. 
 
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 physician reviewer found 
that the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require 
intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies, such as 
physical and occupational therapy, but the documentation does not support that your functional status requires 
or can tolerate an 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a non-Medicare provider on 
February 5, 2020. 
 
You asked the Plan to pay for the dental services from a non-Medicare provider. You say that your wife has the 
same plan as you and has been reimbursed for dental services provided by this same dentist. The Plan denied 
your request. The Plan says the requested dental provider is privately contracted and not enrolled in Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were non-urgent and non-emergent. This provider has opted out of the 
Medicare program. Therefore, we decided that the Plan does not have to pay for dental services provided by a 
non-Medicare provider on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a collapsible scooter (E1399). 
 
You asked the Plan to pre-approve the collapsible scooter. You say that your current wheelchair is too heavy to 
load on a vehicle. The Plan denied your request. The Plan says the requested item is for use outside the home 
and is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a collapsible scooter (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bath safety step. 
 
You asked the Plan to pre-approve a bath safety step. You say that this will help you get into the bathtub. The 
Plan denied your request. The Plan says that this is not a covered benefit. 
 
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 bath safety step.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by the requested 
provider. 
 
You asked the Plan to pre-approve the acupuncture services. The Plan denied your request. The Plan says the 
Plan will not authorize medically necessary care outside the health Plan network unless that care is not 
available within the 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 
acupuncture services to be provided by the requested provider.