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

We decided that the Plan does not have to pre-approve temporary crowns (D2970 x6), periodontal maintenance 
(D4910), pontic - porcelain fused to high noble metal (D6240 x3), and retainer crowns - porcelain fused to high 
noble metal (D6750 x3). 
 
You asked the Plan to pre-approve 6 temporary crowns, periodontal maintenance, 3 pontic - porcelain fused to 
high noble metal, and 3 retainer crowns - porcelain fused to high noble metal. You say that the services are 
necessary. The Plan denied your request. The Plan says the requested services are 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 
temporary crowns (D2970 x6), periodontal maintenance (D4910), pontic - porcelain fused to high noble metal 
(D6240 x3), and retainer crowns - porcelain fused to high noble metal (D6750 x3).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under 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 Prolia.  
 
Benefits for this drug 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Auricular nerve stimulator device for the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health 
problem. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the published literature on the proposed technology is largely limited to case reports and or animal 
models. There are otherwise publications that explore potential anatomical mechanisms that may benefit from 
the use of this technology. Overall, the body of available literature on this technology is mostly limited. These 
publications do not otherwise permit conclusions on the efficacy of the proposed service/technology--
particularly in the management of non-specific chronic pain syndromes. In this setting the proposed service 
would be best classified as being experimental or investigational and therefore 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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Auricular nerve stimulator device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve joint surgery (CPT Codes: 29826 and 29823). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not 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 the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found codes 29826 and 29823 are experimental for use in cases of adhesive capsulitis. They should 
not be approved. More research is needed to show they are useful in this diagnosis. 
 
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 joint surgery (CPT Codes: 29826 and 29823).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Januvia (J8499). 
 
You asked the Plan to pre-approve Januvia. You say that the enrollee did well on a trial of this medication. The 
Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 
prescription drug 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 Januvia (J8499).  
 
Benefits for Januvia 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D0120, D1999, D1110) provided by an out-
of-network (OON) dentist on May 15, 2020. 
 
You asked the Plan to pay for OON dental services. You say that these services are covered under your plan. 
The Plan denied your request. The Plan says these services are not covered from out-of-network providers. 
 
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 pay for dental 
services (D0120, D1999, D1110) provided by an out-of-network (OON) dentist on May 15, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT, a special kind of picture of your heart without contrast (dye) 
(CPT Code 75571). 
 
You asked the Plan to pre-approve the CT scan. You say that you experience discomfort and pain in your arms. 
The Plan denied your request. The Plan says that the service is not necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our physician reviewer 
found based on this, no pharmacologic therapy is recommended. The results of a coronary CT scan would 
change therapy if coronary calcium score was elevated. Literature supports its use in this circumstance. CT 
Scan of the coronary arteries is medically reasonable and 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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve CT, a special kind of picture of your heart without contrast (dye) (CPT Code 75571).  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device (C2624, 33289). 
 
You asked the Plan to pre-approve a CardioMEMS device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, 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 a CardioMEMS device. 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. Moreover, concerns have been raised about potential bias in this trial calling into question the 
results. Therefore, 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 a CardioMEMS device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device (C2624, 33289).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat 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 raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair for the use outside of the home. 
 
You asked the Plan to pre-approve a power wheelchair for the use outside of the home. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a 
covered benefit when being requested for outside of the home. 
 
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 power wheelchair for the use outside of the home.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Purewick Urine collection device, female external 
catheter, and accessory kit (A9270). 
 
You asked the Plan to pre-approve Purewick Urine collection device (A9270). You say that this device has 
been an absolute miracle and you are requesting coverage for the device and related supplies going forward due 
to continued medical need. The Plan denied your request. The Plan says this item is excluded and therefore is 
not a covered benefit. 
 
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 Purewick Urine collection device (A9270). have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Purewick Urine collection device, female external catheter, and accessory kit 
(A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair, with or without wheels (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that a shower chair is medically necessary. The 
Plan denied your request. The Plan says a shower chair 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 for you 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, with or without 
wheels (E0240).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.  
 
It is also noted that you have an over the counter purchase benefit that this item could be purchased under.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration 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 there is no high level medical evidence that the use of bone marrow aspirate increases 
the rate of fusion. 
 
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 bone marrow aspirate remains 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Modafinil (J8499). 
 
You asked the Plan to pre-approve Modafinil. You say that this medication has been proven effective for the 
enrollee's condition. The Plan denied your request. The Plan says coverage of this medication is the 
responsibility of the enrollee's prescription drug 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 Modafinil (J8499).  
 
Benefits for Modafinil 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on 
November 5, 2019. 
 
You asked the Plan to waive the copayment for the specialist office visit. You say that you feel you should not 
be responsible for this cost share amount you would like the Plan to reconsider your request. The Plan denied 
your request. The Plan says you had an office visit with a specialist on the date of service at issue in this 
appeal. The Plan says that 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 $40 
copayment for specialist visits.  
 
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a specialist 
office visit on November 5, 2019. You have been asked to pay a $40 copayment for the specialist office visit. 
The specialist office visit falls within the Physician/Practitioner 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 the specialist office visit provided on November 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 225 skin barrier wipes (A5120) per 90 days. 
 
You asked the Plan to pre-approve the skin barrier wipes. You say that you have been using these wipes for 6 
years and you've never had a problem or needed an authorization. You require this number of wipes because 
150 does not last 6 months. The Plan denied your request. The Plan says the request for 225 per 90 days 
exceeds the Medicare quantity limit. The plan approved the maximum quantity of skin barrier wipes of 150 per 
6 months. 
 
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. The plan has approved the Medicare allowable of 150 per 6 months. 
Based on this information, we decided that Medicare rules for coverage of skin barrier wipes have not been 
met. Therefore, we decided that the Plan does not have to pre-approve 225 skin barrier wipes (A5120) per 90 
days.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Foundation One Heme test 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 the enrollee's diagnosis is not an indication for this test. 
 
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 does not have a diagnosis of acute myelogenous leukemia, myelodysplastic syndrome, and 
she does not have a myeloproliferative neoplasm for which clinical, laboratory, and pathologic assessment are 
nondiagnostic, or higher-risk myelofibrosis with progression on therapy. 
 
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 Foundation One Heme test for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Rizatriptan 10 mg tablet. 
 
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the 
member's contractual policy. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Rizatriptan 10 mg 
tablet.  
 
Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.