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

We decided that the Plan does not have to pre-approve complete upper dentures and partial lower dentures.
You asked the Plan to pre-approve the dentures. You say that when you would eat with your previous dentures,
you would chew the inside of your left cheek. You say that you made 3 more visits to try and fix the dentures
and that each time they would make and adjustment, but the problem would persist. You say that this would
result in your having to wait 10 days for your cheek to heal before you could go back for another adjustment.
You say that you cannot go back there again. You say that it is very painful. The Plan denied your request. The
Plan says the benefit limit for dentures has been reached for the 2020 plan year. The Plan says that they
contacted their in-network dentist, who is willing to assist with your current dentures.
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 benefit for dentures is limited to
once every 5 years. The records show that you received coverage for dentures in August of 2019. This means
that your benefit for dentures is currently exhausted. Therefore, we decided that the Plan does not have to preapprove
complete upper dentures and partial lower dentures.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tracheotomy tube change (31502) provided. 
 
You asked the Plan to pay for a tracheotomy tube change. You say that this service was performed in an office 
with a hospital standard of care. The Plan denied your request. The Plan says this is a facility-only procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly and 
facility-only codes are identified by a ?NA? in the ?NA Indicator? field. 
 
We find that CPT code 31502 is not supported in the medical record. Specifically, this code has a ?NA? in the 
?NA Indicator? field, indicating it is a facility-only code, but it was billed with POS 11, a non-facility place of 
service. Based on this information, we decided that Medicare rules for coverage of a tracheotomy tube change 
have not been met. Therefore, we decided that the Plan does not have to pay for a tracheotomy tube change 
(31502) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on May 6, 2020 and 
May 13, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says all 
services provided by out-of-network providers requires prior authorization except for emergency, urgent care 
or dialysis while temporarily out of the plan's service area. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for nurse practitioner services provided on May 6, 2020 and May 13, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper and lower denture (D5110 and 
D5120). 
 
You asked the Plan to pre-approve the complete upper and lower denture. You say that you had surgery in your 
mouth and need new dentures that fit. You say that you are not able to eat and it's causing you to lose weight. 
The Plan denied your request. The Plan says services are only covered once every five years. 
 
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, you also have a maximum benefit of 
one complete or partial denture every five plan years. You received complete dentures on August 24, 2018, 
which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete 
upper and lower denture (D5110 and D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intubation (31500) and critical care services (99291) 
provided on October 24, 2019. 
 
You asked the Plan to pay for the intubation and critical care services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation 
submitted does not support the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 31500 is intubation, endotracheal, emergency procedure. 
 
The CPT Code Manual definition of code 99291 is citical care, evaluation and management of the critically ill 
or critically injured patient; first 30-74 minutes.  
 
We asked our coder 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 intubation and critical care services. Our reviewer says 
that CPT codes 31500 and 99291 do not meet criteria for billing or reimbursement consideration. Our reviewer 
found documentation did not include emergency room progress note to support CPT 99291, or that an 
endotracheal intubation was performed.  Therefore CPT 31500 and CPT 99291 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the intubation and critical care services have not been met. Therefore, we 
decided that the Plan does not have to pay for intubation (31500) and critical care services (99291) provided on 
October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bi-level positive airway pressure supplies (A4604, A7030, 
A7031, A7038, E0471, E0562) provided on March 20, 2020. 
 
You asked the Plan to pay for bi-level positive airway pressure supplies. You say that this is supported in the 
records. The Plan denied your request. The Plan says there is not a valid order for these items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid order for the supplies provided in this case. The order in the file does not 
indicate the specific items provided. The record shows that the Plan made several attempts to obtain the 
necessary documentation without success. Therefore, we decided that the Plan does not have to pay for bi-level 
positive airway pressure supplies (A4604, A7030, A7031, A7038, E0471, E0562) provided on March 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for craniosacral therapy. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a Medicare 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 pre-approve the referral. Our reviewer says that the 
requested referral is not considered medically reasonable and necessary in this case. Our physician reviewer 
found at the present time the use of craniosacral therapy is not recognized by any professional societies for use 
in the management of migraines or any other form of headache disorder. The literature on the use of this 
specific form of therapy is otherwise largely preliminary in nature. There remains a need for further study of 
the proposed course of treatment in large well-designed clinical studies to formally determine if it is of any 
clinical benefit or utility. In this setting the therapy would be considered to be investigational in nature and 
therefore would not be 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 referral have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral for craniosacral therapy.
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 July 2, 2020.

You asked the Plan to waive the copayment for the ER visit. You say that you went to the hospital for a CT scan.  You said they found a crack in your hip and they sent you to the ER until they could figure out what to do with you.  You said you just waited in the ER in a wheelchair and didn't receive any treatment. 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 $75 copayment for ER visits. 

You have been asked to pay a $75 copayment for the ER visit. This copayment applies regardless of the extent of services you receive in the ER. 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 July 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics for the enrollee. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied 
your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a presbyopia-correcting intraocular lens (P-C IOC) 
(V2788). 
 
You asked the Plan to pre-approve the P-C IOL. You say that the lens is medically necessary. The Plan denied 
your request. The Plan says this type of lens is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives a P-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the P-C IOL and a 
conventional IOL.  
 
While a P-C IOL may be appropriate for you, neither the Plan nor Medicare covers the presbyopia-correcting 
feature of a P-C IOL. Therefore, we decided that the Plan does not have to pre-approve a presbyopia-correcting 
intraocular lens (P-C IOC) (V2788).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric 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 total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a book scanner/reading machine. 
 
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not primarily medical in nature. 
 
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 book scanner/reading machine.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional physical therapy visits. 
 
You asked the Plan to pre-approve 6 additional physical therapy visits. You say that you want 10 additional 
visits. 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 6 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 prior therapy for this 
condition and additional visits were already authorized to review an independent 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 6 additional physical therapy visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve powered upper extremity range of motion assist device 
(L8702). 
 
You asked the Plan to pre-approve the powered upper extremity range of motion assist device. You say that 
you would like reconsideration because this equipment is medically necessary. The Plan denied your request. 
The Plan says this equipment is experimental. 
 
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 powered upper extremity range of 
motion assist device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the requested device is not reasonable and 
necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of a malformed 
body member. A review of the literature reveals additional controlled studies of the MyoPro or upper extremity 
paralysis after stroke are needed with larger patient groups, consistent improvements of relevant outcome 
functional measures,  and long term follow up. 
 
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 powered upper extremity range of motion assist device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve powered upper extremity range of motion 
assist device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep gum and root cleaning. 
 
You asked the Plan to pre-approve deep gum and root cleaning. You say that you would like the plan to 
reconsider their denial. 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 deep 
gum and root cleaning.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the acupuncture treatments. 
 
You asked the Plan to pre-approve the acupuncture treatments. You say that you recently had spinal cord 
compression surgery and you would like to relieve residual pain in your upper back and neck. The Plan denied 
your request. The Plan says this service is not covered and the enrollee does not meet the Medicare criteria as 
Medicare covers for lower back pain only and not for upper back and neck areas. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, Medicare covers acupuncture only for lower back 
pain. You requesting acupuncture for your upper back and neck. Therefore, we decided that the Plan does not 
have to pre-approve the acupuncture treatments.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says rules for IRF care have not been met. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it 
does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the 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 IRF admission and services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve aflibercept (Eylea). 
 
You asked the Plan to pre-approve Eylea. You say that the enrollee has already tried Avastin. The Plan denied 
your request. The Plan says the enrollee has not tried and failed Bevacizumab ophthalmic. 
 
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 Eylea. Our physician reviewer found 
that the Plan requires a trial of Bevacizumab (Avastin) ophthalmic before they will approve the requested drug. 
The requesting physician stated that Avastin had been tried. However, the notes provided for review, did not 
show documentation of Avastin having been tried and failed, or planned for trial to support this statement. 
Therefore, based on the provided documentation, this enrollee has not yet tried and failed Avastin. Avastin and 
Eylea are similar in their action, and have an essentially equal effectiveness and safety profile according to 
current literature. There was no indication this enrollee would have an adverse reaction, or have less 
effectiveness from the preferred Avastin. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve aflibercept (Eylea).