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

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the office visit. You say that you would like reconsideration because you 
would like to remain with your current provider to monitor and treat your condition. The Plan denied your 
request. The Plan says these services are 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 medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the manual wheelchair, for the enrollee. 
 
You asked the Plan to pre-approve the manual wheelchair. You say that the durable medical equipment is 
medically necessary. The Plan denied your request. The Plan says a mobility device is not a covered benefit 
under Medicare for beneficiaries who reside in a SNF. 
 
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 manual wheelchair have not been met. The enrollee resides in a 
SNF and Medicare does not cover this equipment under the circumstance. The rules say that a SNF may not 
bill for DME furnished to its Part A inpatients as necessary DME must be supplied to the beneficiary as part of 
SNF services. Therefore, we decided that the Plan does not have to pre-approve the manual wheelchair, for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care 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 exceeds the mobility criteria for SNF admission. 
 
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 the services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does not meet severity of illness or intensity of service criteria for 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) care for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6532. 
 
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings. The Plan 
denied your request. The Plan says the compression stockings are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6532 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6532.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture, complete lower denture, 
surgical extractions and alveoloplasty. 
 
You asked the Plan to pre-approve the complete upper denture, complete lower denture, extractions and 
alveoloplasty. You say that the extractions are a medical necessity. You say that your primary care physician 
agrees to the treatment. 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 
complete upper denture, complete lower denture, surgical extractions and alveoloplasty.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 72 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you require dialysis 3 times a week and the 
additional trips are needed. The Plan denied your request. The Plan says this request exceeds the benefit 
frequency limitation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 30 on way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 72 additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a new set of dentures.
You asked the Plan to pre-approve the dentures. You say that you need to have teeth pulled and will need new
dentures. The Plan denied your request. The Plan says one set of dentures is covered every 5 years. The Plan
also says that you have exhausted your dentures 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, dentures are limited to one per arch
every five years. The record shows that you received a maxillary partial denture and a mandibular partial
denture on September 9, 2019 and your dentures benefit has been exhausted. Therefore, we decided that the
Plan does not have to pre-approve a new set of dentures.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission after a total knee 
replacement. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient admission is 
medically necessary. The Plan denied your request. The Plan says the procedure can be performed on an 
outpatient basis. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient services are met. Our 
physician reviewer found there is no medical need for inpatient admission after this surgery. It can safely be 
performed as an outpatient or observational stay. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an inpatient hospital admission after a total knee replacement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing 4 quadrants 
(D4341). 
 
You asked the Plan to pre-approve the dental services. You say that you would like to appeal the decision to 
denial the your dental deep cleaning. The Plan denied your request. The Plan says the number of teeth do not 
meet the criteria. The enrollee does not have the minimum number of teeth per quadrant required for the 
requested deep cleaning services. 
 
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 dental 
services 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 dental services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the code D4341 is reserved for situations where there are four or more periodontally 
involved teeth in a quadrant. In this case the remaining teeth in the upper arch are #7 and #11 and in the lower 
arch are #21, #27 and #28. There are a maximum of two teeth in any one quadrant and as such code D4341 is 
not applicable in any of the quadrants. As the selected code is not applicable, there is no medical necessity for 
the requested treatment. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planing 4 quadrants (D4341).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor and supplies 
(receiver, sensor, and transmitter) for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the Dexcom G6 is the non-preferred monitor. 
 
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 monitor. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no evidence that the enrollee has used the health plan?s preferred CGM and been unsuccessful 
with or intolerant of the device.  There is no clear documentation as to why the requested meter is necessary 
over the health plan?s preferred meter.  The documentation does not currently show that the requested meter is 
medically necessary and 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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Dexcom G6 continuous glucose monitor and supplies (receiver, sensor, and transmitter) 
for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies, Purewick female external 
catheters (A9270). 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are requesting coverage because 
your doctor ordered and you need it. The Plan denied your request. The Plan says this item is not covered under 
Medicare or the plan. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies, Purewick 
female external catheters (A9270).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services for your jaw problem. 
 
You asked the Plan to pre-approve the requested services. You say that the dentist will only be working on 
your jaw. The Plan denied your request. The Plan says dental treatment related to temporomandibular disorders 
is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically reasonable and 
necessary.  
 
We looked at the file, and Medicare rules. dental treatment related to temporomandibular disorders (TMD) are 
not covered by your plan. Therefore, we decided that the Plan does not have to pre-approve dental services for 
your jaw problem.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Continuous Glucose Monitor (CGM) with supplies (K0553, 
K0554). 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM is medically necessary. The 
Plan denied your request. The Plan says that rules for coverage are not met. 
 
The Plan follows Medicare rules. Medicare rules say that CGM's are covered when 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 CGM and supplies. Our reviewer 
says that the CGM is medically necessary. Our physician reviewer found the enrollee is on 4 shots-a-day 
insulin regimen and is prescribed checking glucose levels 4 times daily. More frequent insulin adjustments 
would likely be made if the enrollee had the CGM. 
 
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 CGM and supplies have been met. Therefore, we decided that the Plan has 
to pre-approve a Continuous Glucose Monitor (CGM) with supplies (K0553, K0554).  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the CT scan of the thorax without contrast material (CPT Code 
71250) for the enrollee. 
 
You asked the Plan to pre-approve the CT scan. You say that the pulmonologist wants a CT scan before the 
visit with the enrollee. The Plan denied your request. The Plan says that enrollee does not have an x-ray or 
failed conservative treatments to require a CT scan at this time. 
 
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 the patient has alpha 1-antitrypsinase deficiency.  CT scan (without contrast) of the chest is necessary for 
the Pulmonologist to stage and evaluate the severity of disease that could not be obtained through other 
imaging methods or exam.  It is necessary for a thorough evaluation of the patient's baseline condition. 
 
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 the CT scan of the thorax without contrast material (CPT Code 71250) for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRI, spinal canal and contents, lumbar; without 
contrast material (CPT Code 72148). 
 
You asked the Plan to pre-approve the MRI. You say that you have back pain. The Plan denied your request. 
The Plan says you need an x-ray and conservative treatments prior to MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our physician reviewer found 
there was not record of adequate documentation of any treatment plan regarding low back pain nor was there 
any documentation, or sufficient documentation, regarding severity of or therapy for back pain. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the MRI, spinal canal and contents, lumbar; without contrast material (CPT Code 72148).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on 
January 14, 2020.  
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you should not have to 
pay the copayment because you did not need the ambulance but the officers forced you to take the ambulance. 
The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $175 
copayment per one-way trip for emergency ambulance services and non-emergency ambulance services.  
 
You have been asked to pay a $175 copayment for the ambulance transport. The ambulance transport falls 
within the ?Ambulance services? benefit category. The record shows you received the ambulance services. 
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 ambulance transport provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
You asked the Plan to provide a tiering exception for Dexilant DR. The Plan did not grant this request. We 
received this case to conduct an independent review.  
 
Medicare law and Plan rules do not allow tiering exceptions for non-formulary drugs being covered 
through a formulary exception. The documentation in the record shows that Dexilant DR is currently being 
covered for the enrollee through a formulary exception. Therefore, our decision is the Plan is not required 
to provide a tiering exception for Dexilant DR.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab work provided on April 1, 2020 by an out of network 
(OON) provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for 
payment. The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for lab work provided on April 1, 2020 by an out of 
network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an X-Ray examination professional component 
(reading/reporting) provided on January 30, 2020. 
 
You asked the Plan to pay for X-Ray exam. You say that this procedure was rendered in the appropriate place 
of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the outpatient hospital Place of Service (POS) code was billed on this claim however this service was 
performed during an inpatient hospitalization. 
 
The Plan must follow Medicare rules. Medicare rules say that when a physician provides the professional 
component/interpretation of a diagnostic test, the Place of Service (POS) code assigned by the physician will be 
the setting in which the beneficiary received the technical component of the service.  
 
We looked at the file and Medicare rules. The technical component of this testing was performed in an 
inpatient hospital setting, therefore the Place of Service (POS) code 22 ? indicating an on-campus outpatient 
hospital setting ? is not appropriate for this claim. Based on this information, we decided that Medicare rules 
for coverage of X-Ray exam have not been met. Therefore, we decided that the Plan does not have to pay for 
an X-Ray examination professional component (reading/reporting) provided on January 30, 2020.