Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G arm prosthesis for the enrollee. 
 
You asked the Plan to pre-approve MyoPro Motion G arm prosthesis. You say that this item is medically 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. 
 
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 MyoPro 
Motion G arm prosthesis. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the medical records provided do not meet 
the requirements listed in the Social Security Act, Section 1862 (a)1(A) and the 42 CFR ?411.15(k) for 
Medicare coverage for the powered upper extremity range of motion assist device, elbow, wrist, hand, finger, 
single or double upright(s), includes microprocessor, sensors, all components and accessories, custom 
fabricated (L8702). At this time the requested robotic orthosis is not proven to be more beneficial for treatment 
of the patient's medical condition/function of hemiparesis after stroke than any available standard therapy. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of MyoPro Motion G arm prosthesis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a MyoPro Motion G arm prosthesis for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nutrisystem weight loss meal plan. 
 
You asked the Plan to pre-approve Nutrisystem weight loss meal plan. You say that you have an autistic son 
and do not want to have to bring him to all the meetings. The Plan denied your request. The Plan says 
counseling to help you lose weight is available through your primary care doctor or practitioner. The Plan says 
the EOC states that the only meal plan available is for 7 days or 14 pre-cooked meals immediately following a 
discharge after an inpatient stay. The Plan states the information received did not indicate that you were 
recently discharged from the hospital. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
This is not covered under Medicare or the Health Plan. Therefore, we decided that the Plan does not have to 
pre-approve Nutrisystem weight loss meal plan.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an oral occlusive device. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the submitted records show that you have 
arthritic changes of the temporomandibular joint (TMJ) and a diagnosis of inflammation of the jaw muscles 
(interstitial myositis). The requested oral occlusive device is not for the treatment of teeth or structures 
supporting the teeth but for the treatment of a medical condition. The services are reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve an oral occlusive device.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that this facility is within walking distance and 
they have great reviews. The Plan denied your request. The Plan says there are in-network providers available 
for these services. The Plan says that the member's primary care physician did not refer these services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bariatric surgery visit (99199) provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the bariatric surgery visit. You say that you saw the OON provider in 2012. 
The Plan denied your request. The Plan says the service requested, bariatric surgery, is available in-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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the bariatric surgery visit (99199) provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oncology colorectal screening test. 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says this 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 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 test. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found you had the Cologuard TM test in 2019. This test is only covered once every three years. The requested 
oncology colorectal screening test is not medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an oncology colorectal screening test.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an outpatient spinal cord stimulator trial for the enrollee. 
 
You asked the Plan to pre-approve the trial. You say that this is medically necessary. The Plan denied your 
request. The Plan says there was no documentation of extensive discussion and education about the risks and 
benefits of this therapy. 
 
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 trial. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the diagnosis is degenerative low back pain. There are no neurologic deficits. The criteria for the 
stimulator is not met with 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 trial have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an outpatient spinal cord stimulator trial for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 4 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve 4 additional PT visits. You say that 4 additional PT visits are medically 
necessary to maximize strength and function. The Plan denied your request. The Plan says the 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 4 additional PT 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 the patient continues to have weakness and range of motion 
limitations despite 30 visits of therapy. The patient has had extensive therapy for this condition, and it appears 
the patient does not require the unique skills of a professional therapist to safely and effectively provide 
treatment. Services do not need to be safely and effectively performed only by a therapist, or under the 
supervision of a therapist. The patient appears to have been educated on home exercises and the  specialized 
skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a 
program to maintain the patient's current condition or to prevent or slow further deterioration. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 4 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 4 additional physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom wheelchair cushion (E1399). 
 
You asked the Plan to pre-approve the custom wheelchair cushion. You say that this type of cushion is 
medically necessary. The Plan denied your request. The Plan says the requested customized, brand name 
wheelchair cushion is not covered. The plan has authorized a standard wheelchair cushion. 
 
The Plan must follow Medicare rules. Medicare rules say that customized wheelchair cushions are non-
covered.  
 
We looked at the file and Medicare rules. The requested item is not covered. Based on this information, we 
decided that Medicare rules for coverage of the custom wheelchair cushion have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a custom wheelchair cushion (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oral sleep apnea appliance (E0486) to be provided 
by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the oral sleep apnea appliance. You say that the oral appliance is medically 
necessary. The Plan denied your request. The Plan says the requested service is not emergent or pre-authorized. 
There are network providers available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the oral sleep apnea appliance (E0486) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the new patient office or other outpatient visit (99204) 
to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the new patient office or other outpatient visit. You say that you are afraid 
to do the procedure with a specialist whose rating is not good. The Plan denied your request. The Plan says 
they are able to provide the requested service in 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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the new patient office or other outpatient visit (99204) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve a second opinion. You say that you would like to get a second opinion. The 
Plan denied your request. The Plan says there are in-network providers who can provide a second opinion. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a second opinion to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crowns and prefabricated post and core in addition 
to crowns. 
 
You asked the Plan to pre-approve the crowns and prefabricated post and core in addition to crowns. The Plan 
denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 
crowns and prefabricated post and core in addition to crowns.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvetranscranial magnetic stimulation for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysa number of conditions have 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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not meet the criteria of taking antidepressant medication during the current episode utilizing the criteria above. Based on the information provided, you do not meet the clinical criteria for the use of TMS therapy as you have tried several different agents as noted above not in the same depressive episode from the different classes. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthe services have not been met.Therefore, we decided that the Plandoes not haveto pre-approvetranscranial magnetic stimulation for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services (CPT Code 97813 and CPT Code 
97814). 
 
You asked the Plan to pre-approve acupuncture services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says this is not covered by the Plan or Medicare. 
 
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, the enrollee's EOC states that acupuncture is not 
covered under any condition. Therefore, we decided that the Plan does not have to pre-approve acupuncture 
services (CPT Code 97813 and CPT Code 97814).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair impact guards (K0108). 
 
You asked the Plan to pre-approve the wheelchair impact guards. You say that the guards are medically 
necessary. The Plan denied your request. The Plan says these guards are not primarily medical in nature and 
therefore are non-covered. 
 
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 wheelchair impact guards (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee orthoses (L1851 x2). 
 
You asked the Plan to pre-approve the knee orthoses. You say that the orthoses are medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that this type of brace is covered when there was recent 
injury or surgery, or when there is documented instability in the joint on exam. 
 
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 knee orthoses. Our reviewer says 
that the knee orthoses requested are not medically necessary. Our physician reviewer found there is no 
documentation indicating the enrollee meets the requirements for coverage. There is no documentation of 
recent injury or surgery, and no documentation of instability on exam. 
 
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 knee orthoses have not been met. Therefore, we decided that the Plan does 
not have to pre-approve knee orthoses (L1851 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you need this due to medical necessity and 
undue pain and suffering. 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.
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 it is in your best interest to 
receive physical therapy. 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 you had prior therapy for this condition and have 
been educated in 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 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.