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

 
We decided that the Plan does not have to pay for the ophthalmology services provided on June 12, 2020 by an 
out of network provider. 
 
You asked the Plan to pay for the ophthalmology services. You say that you never received a referral response 
from the enrollee's primary care doctor. The Plan denied your request. The Plan says prior authorization was 
required but not requested. 
 
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 has network providers 
available who can provide the services at issue in this appeal. 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 the ophthalmology services provided on June 12, 2020 by an out of network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower partial denture. 
 
You asked the Plan to pre-approve the lower partial denture. You say that your bottom plate broke and you 
need a replacement. You say that you cannot to pay the high cost. The Plan denied your request. The Plan says 
this service is only allowed one time in 5 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 5 years. The Plan paid for a lower partial denture provided on August 22, 
2016, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the 
lower partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted special services (99199). 
 
You asked the Plan to pre-approve the unlisted special services. You say that your teeth are weak and breaking 
due to chemotherapy and needs to be extracted. You feel it should be covered because the plan provides 
coverage for jaw cancer so it should also cover for breast cancer. The Plan denied your request. The Plan says 
this service is not covered under the plan 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 
unlisted special services (99199).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitor (CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they 
are medically reasonable and necessary and replace a blood glucose monitor.  
 
We looked at the file and Medicare rules. Medicare rules also say that therapeutic CGMs are covered only 
when a patient has been performing four or more blood glucose testing's every day and is insulin-treated with 
at least three or more daily injections of insulin or a Medicare-covered continuous subcutaneous insulin 
infusion (CSII) pump. The file shows that you do not test your blood glucose levels at least four or more times 
a day and you are neither insulin-treated at least 3 times per day nor have a CSII pump. Therefore, we decided 
that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in bath tub. 
 
You asked the Plan to pre-approve a walk-in bath tub. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a walk-in bath tub 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. 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 walk-in bath tub.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex implantation. 
 
You asked the Plan to pre-approve a Vertiflex implantation. You say that the requested Vertiflex implantation 
is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex implantation 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 a Vertiflex implantation. Our reviewer 
says that the requested Vertiflex implantation is not medically necessary. Our physician reviewer found the 
enrollee is with chronic bilateral low back pain without sciatica. The enrollee is post-laminectomy syndrome 
lumbar spine/lumbar spondylosis/lumbar degenerative disc disease. The spacer device remains experimental. 
More research is needed to show the safety and efficacy of the device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Vertiflex implantation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex implantation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture. 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you do not believe that you 
need to have all of your teeth removed to get dentures, when there are only 2 teeth that need to be removed. 
You also say that your bottom teeth could be saved if you got a partial denture. The Plan denied your request. 
The Plan says this service is 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. The contract clearly states that the Plan only covers complete dentures. 
Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. You say that you were told you would be able to 
see this provider. The Plan denied your request. The Plan says the provider you requested is not part of your 
primary care physician's 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 contract with 
the Plan also says that the plan requires you to receive care from providers who are part of your primary care 
physician's (PCP) specialty network. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 pressure reducing mattress. 
 
You asked the Plan to pre-approve pressure reducing mattress. You say that the enrollee's current mattress 
cannot be repaired and requires immediate replacement. The Plan denied your request. The Plan says the denial 
of authorization for this item is correct, because the enrollee does not have ulcers. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 2 pressure reducing support surface is only 
covered if at least 1 of the 3 above-listed clinical criteria have been met.  
 
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 pressure reducing mattress. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested mattress. Our physician 
reviewer found the documentation does not show that the enrollee has several stage 2 pressure ulcers or a stage 
3 or 4 pressure ulcer on the trunk of the body or pelvis or has had recent surgery for this. The records do not 
indicate that the enrollee has ulcers. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pressure reducing mattress have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Group 2 pressure reducing mattress.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750). 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says this service is not 
covered under the enrollee's plan. 
 
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 a 
crown (D2750).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with codes A6530 and 
A6531. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. 
 
Medicare rules also say that compression garments are covered only for patients with burn injuries or open 
venous stasis ulcers.  
 
The record does not show that you have burn injuries or open venous stasis ulcers. 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 codes A6530 and 
A6531.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The medical 
record supports a need for physical and occupational therapy but it does not support a plausible expectation that 
the enrollee can participate in an intensive rehabilitation program. There is not a reasonable expectation that 
this enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (PWC). 
 
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 you do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that a PWC is covered when a beneficiary's mobility 
limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker 
 
We looked at the file and Medicare rules. The file shows that your mobility limitation is sufficiently resolved 
with the use of a straight cane. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair (PWC).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three removals of lateral exostosis (D7471 x3). 
 
You asked the Plan to pre-approve the removals of lateral exostosis. You say that you were told that your 
insurance would cover the procedures. You also say that you are on a fixed income and need help paying for 
these surgeries. The Plan denied your request. The Plan says this service is not covered under your benefit 
package. 
 
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 three 
removals of lateral exostosis (D7471 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint radiofrequency neurolysis 
(64635). 
 
You asked the Plan to pre-approve a lumbar/sacral facet joint radiofrequency neurolysis. You say that this 
procedure is medically necessary and the records should support the necessity of the service. The Plan denied 
your request. The Plan says the requested service is considered a benefit exclusion and 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 a lumbar/sacral facet joint 
radiofrequency neurolysis. our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the standard for a positive test is greater 
than 80% pain relief.  This was not achieved in either set of MBBs.  Therefore, the diagnostic tests are negative 
and alternative pain generators should be identified.  The requested procedures are not medically reasonable or 
necessary 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Lumbar/Sacral Facet Joint Radiofrequency Neurolysis have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a lumbar/sacral facet joint radiofrequency 
neurolysis (64635).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four periodontal scalings and root planings. 
 
You asked the Plan to pre-approve the scalings and planings. You say that you need a deep cleaning, but are 
unable to afford the cost of it. The Plan denied your request. The Plan says this service is 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 four 
periodontal scalings and root planings.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial (63650). 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators may be covered as therapy for 
relief of chronic intractable pain, provided that specific criteria is met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a spinal cord stimulator trial. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not 
have any evidence based indication for a spinal cord stimulator trial. Therefore, the request is considered not 
medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a spinal cord stimulator trial have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a spinal cord stimulator trial (63650).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a shower chair is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve betadine or iodine swabs. 
 
You asked the Plan to pre-approve these services. You say that you have a catheter and this is the only method 
you can use to clean yourself. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that DME is equipment that can withstand repeated 
use and serves a purpose that is primarily medical in nature. 
 
We looked at the file and Medicare rules. The requested services are betadine/iodine wipes, which are not 
reusable and do not serve a purpose that is primarily medical in nature. Based on this information, we decided 
that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve betadine or iodine swabs.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient endocrinology services to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the endocrinology services. You say that you are appealing because you 
only had a consult and need to go for more tests and follow up. After the first consult you went for the MRI and 
they found a tumor. The Plan denied your request. The Plan says enrollee's must receive their medical services 
from an in-network provider with the exception being urgent or emergent services. Non-emergent services with 
non-contracted providers require prior authorization before services being rendered. 
 
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 outpatient endocrinology services to be provided by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on January 20, 2020. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee's hospice was terminated prior to 
the date of service. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on January 8, 2020. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on January 20, 2020.