Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit with tertiary level 
neurosurgeon. 
 
You asked the Plan to pre-approve the outpatient office visit. You say that the enrollee is returning for a follow 
up visit. Please see clinical notes. The Plan denied your request. The Plan says it is not medically necessary for 
the enrollee to go to a tertiary neurosurgeon. The plan approved an outpatient office visit with a non-tertiary 
neurosurgeon. 
 
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 provider at issue in this case is a tertiary level plan participating provider. 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 outpatient office visit. Our reviewer says that the requested 
items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no medical need to go to a tertiary specialist. The enrollee has a routine spine condition that can 
safely be managed by the non-tertiary neurosurgeon. 
 
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 outpatient office visit have not been met.  
 
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 the outpatient office visit. Therefore, we decided that 
the Plan does not have to pre-approve the outpatient office visit with tertiary level neurosurgeon.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ambien Tablet. 
 
You asked the Plan to pre-approve Ambien Tablet (J8499). You say that you want the enrollee treated with this 
drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B 
benefit. 
 
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 Ambien Tablet.  
 
Benefits for Ambien Tablet (J8499) 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MVASI (Q5107). 
 
You asked the Plan to pre-approve MVASI. You say that this is medically necessary. The Plan denied your 
request. The Plan says coverage of this service is the responsibility of Original Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare contractors will pay for covered 
clinical trial services furnished to beneficiaries enrolled in managed care plans. 
 
We looked at the file and Medicare rules. The record shows that the enrollee is enrolled in a clinical trial for the 
treatment at issue. Based on this information, we decided that Medicare rules for coverage of MVASI have not 
been met. Therefore, we decided that the Plan does not have to pre-approve MVASI (Q5107).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an apnea machine battery backup. 
 
You asked the Plan to pre-approve an apnea machine battery backup. You say that the enrollee has electrical 
energy problems in the living area. The Plan denied your request. The Plan says this equipment is not covered 
by Medicare or the Plan. 
 
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. Alternate power 
sources are not considered by Medicare as durable medical equipment Therefore, we decided that the Plan does 
not have to pre-approve an apnea machine battery backup.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildups, including any pins when required 
(D2950) for tooth #'s 23 and 25, retainer crowns (D6750) for tooth #'s 23 and 25, and a pontic (D6240) for 
tooth #24. 
 
You asked the Plan to pre-approve the core buildups, retainer crowns, and pontic. You say that tooth #24 needs 
to be extracted. You also say that the enrollee will need a bridge for tooth #'s 23, 24, and 24. The Plan denied 
your request. The Plan says tooth #'s 23 and 25 do not show radiographic evidence of severe decay requiring 
restoration with crowns, and may be restored with composite restorations. The Plan also says that tooth #24 
may be replaced with a prosthesis of lesser means. 
 
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 the core 
buildups, retainer crowns, and pontic 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 core buildups, retainer crowns, and 
pontic. Our reviewer says that the documentation provided does not meet the criteria for coverage for a fixed 
bridge. Our physician reviewer found the documentation provided was insufficient. The radiographs were 
incomplete to determine if posterior teeth were missing which would not meet the criteria for coverage for a 
fixed bridge. Our reviewer also found that the radiographs included were not of diagnostic quality to determine 
the amount of coronal breakdown of tooth #'s 23 and 25. 

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 core buildups, retainer crowns, and pontic have not been met. Therefore, we 
decided that the Plan does not have to pre-approve core buildups, including any pins when required (D2950) 
for tooth #'s 23 and 25, retainer crowns (D6750) for tooth #'s 23 and 25, and a pontic (D6240) for tooth #24.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fixed maxillary prosthesis on irradiated tissues. 
 
You asked the Plan to pre-approve the fixed maxillary prosthesis. You say that intensive maintenance to the 
enrollee's hard and soft oral tissues is imperative. You also say that this is considered a medical procedure, and 
is only necessary due to the enrollee's cancer diagnosis. The Plan denied your request. The Plan says the dental 
treatment is not related to an extraction prior to radiation or a facial fracture. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
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 a 
fixed maxillary prosthesis on irradiated tissues.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan with 
computed tomography (CT) scan. 
 
You asked the Plan to pre-approve the PET scan with CT scan. You say that the records provided should 
support the necessity of the service in dispute. The Plan denied your request. The Plan says Medicare does not 
cover the requested study for fever of unknown origin. 
 
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 the PET scan with CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve positron emission tomography (PET) scan with computed tomography (CT) scan.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. You say that you do not feel that you are ready to care for 
yourself. The Plan denied your request. The Plan says you do not require daily skilled nursing or therapy 
services. 
 
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 services. Our physician reviewer 
found that you are able to ambulate up to 150 feet with contact guard assistance with a 2 wheeled walker. You 
are able to perform transfers and toileting with contact guard assistance. You require moderate assistance for 
bed mobility due to the sternal precautions. You do not require skilled nursing or skilled therapy services on a 
daily basis. You do not have any parental medication; complex wound care or nutrition given via a feeding 
tube.  You are medically stable without any acute exacerbations of chronic medical problems. Your physical 
function is at or near her baseline.  Therefore, admission to a SNF for inpatient skilled rehab services is not 
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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve blepharoplasty on the upper and lower eyelids. 
 
You asked the Plan to pre-approve blepharoplasty on the upper and lower eyelids. You say that the enrollee 
needs blepharoplasty on the upper and lower eyelids. The Plan denied your request. The Plan says 
blepharoplasty on the upper and lower eyelids is 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 looked at the file and Medicare rules. The photos are illegible and there is no documentation of visual 
fields. Based on this information, we decided that Medicare rules for coverage of blepharoplasty on the upper 
and lower eyelids have not been met. Therefore, we decided that the Plan does not have to pre-approve 
blepharoplasty on the upper and lower eyelids.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a WalkAide device. 
 
You asked the Plan to pre-approve the WalkAide device. You say that you would like reconsideration because 
this device would increase your stability and walking speed as well as increase your ability for community re-
entry. The Plan denied your request. The Plan says you do not meet Medicare coverage for the WalkAide 
because you do not have a spinal cord injury. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for the use of neuromuscular electrical 
stimulation/functional electrical stimulation is limited to spinal cord injury patients for walking. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the WalkAide device have not been met. Specifically, the record does not indicate that you have a 
spinal cord injury. Therefore, we decided that the Plan does not have to pre-approve a WalkAide device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia complicated by emergency conditions (specify) 
(List separately in addition to code for primary anesthesia procedure) (CPT Code 99140) provided on February 
20, 2019. 
 
You asked the Plan to pay for the services. You say that the provider is requesting additional payment due to an 
emergency setting. The Plan denied your request. The Plan says your request is not a covered benefit. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. The cost of this service as payment 
for the services provided is already included in the approved anesthesia procedure. Therefore, we decided that 
the Plan does not have to pay for anesthesia complicated by emergency conditions (specify) (List separately in 
addition to code for primary anesthesia procedure) (CPT Code 99140) provided on February 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopic decompression surgery (62380). 
 
You asked the Plan to pre-approve endoscopic decompression surgery. You say that the records provided 
should support the necessity of the service in dispute. The Plan denied your request. The Plan says this 
procedure is considered experimental and investigational and is not covered by Medicare unless you are 
enrolled in a clinical trial. The plan has confirmed that the enrollee is not participating in a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of endoscopic decompression surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve endoscopic decompression surgery (62380).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve plasma injections for the treatment of hair loss. 
 
You asked the Plan to pre-approve plasma injections. You say that this should be covered. The Plan denied 
your request. The Plan says this is cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We looked at the file and Medicare rules. The submitted medical records indicate that the requested procedure 
is cosmetic and does not serve a medical purpose. Based on this information, we decided that Medicare rules 
for coverage of plasma injections have not been met. Therefore, we decided that the Plan does not have to pre-
approve plasma injections for the treatment of hair loss.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
 
You asked the Plan to pre-approve Aranesp. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that the 
documentation does not support that the requested drug is medically necessary. Our physician reviewer found 
Aranesp is being requested for the treatment of anemia associated to antineoplatic chemotherapy. The 
documentation does not support a history of previous treatment, contraindication, or intolerance to Retacrit. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery backup (battery pack for a CPAP machine). 
 
You asked the Plan to pre-approve a battery backup. 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 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 battery backup (battery pack for a CPAP machine).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says there are no 
daily skilled needs documented. 
 
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 services. Our physician reviewer 
found that the enrollee was admitted to the acute hospital with weakness, recurrent falls, and confusion, and 
was found to have a likely urinary tract infection. Gentle hydration and antibiotics were administered. No 
required skilled nursing services are identified that are required to safely and effectively provide medically 
necessary and reasonable treatment for this enrollee. Although there are identifiable skilled therapy service 
needs, the enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, 
the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Free Style Libre continuous glucose monitor. 
 
You asked the Plan to pre-approve the Free Style Libre. You say that you would like reconsideration because 
this equipment is medically necessary. The Plan denied your request. The Plan says the record does not indicate 
that you check your blood sugar 4 or more times a day, that you are insulin treated 3 or more times a day or that 
you require frequent adjustments. 
 
The Plan must follow Medicare rules. Medicare rules say that Therapeutic continuous glucose monitors and 
related supplies are covered by Medicare when you have been using a Blood Glucose Monitor and performing 
frequent (four or more times a day) testing, are insulin-treated with multiple (three or more) daily injections 
and require frequent adjustment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Free Style Libre have not been met. Specifically, the record does not indicate that you test your 
glucose levels 4 or more times a day, have 3 or more insulin injections per day or need frequent adjustments. 
Therefore, we decided that the Plan does not have to pre-approve the Free Style Libre continuous glucose 
monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hearing aids from a non-Plan vendor. 
 
You asked the Plan to pre-approve the hearing aids. You say that you would like reconsideration because you 
are not happy with the selection at the plan vendor. The Plan denied your request. The Plan says the requested 
vendor is not the Plan's designated hearing aid vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only when furnished by a Plan designated vendor. 
 
We looked at your request, the file, and the Plan's rules. Based on this information, we decided that the Plan's 
rules for coverage of the hearing aids have not been met. Specifically, the Plan requires you to receive hearing 
aids from a Plan designated vendor. The requested vendor is not the Plan's designated hearing aid vendor. 
Therefore, we decided that the Plan does not have to pre-approve hearing aids from a non-Plan vendor.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an MRI provided on June 22, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that the first facility did not have a large 
enough MRI machine so you had to go to a second facility and feel that you should not owe a second 
copayment. 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 $25 
copayment for advanced imaging services provided in a specialist's office.  
 
You have been asked to pay a $25 copayment for an MRI. An MRI falls within the physician/practitioner 
services, including doctor's office visits 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 an MRI provided on June 22, 2020.