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

 
We decided that the Plan does not have to pre-approve the localized delivery of antimicrobial agents (D4381) 
for teeth # 2 through 31. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee has gum disease. You say that 
the use of this intervention would be a much needed help to fight the issue. The Plan denied your request. The 
Plan says the localized delivery of antimicrobial agents is not a covered service. 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the localized 
delivery of antimicrobial agents (D4381) for teeth # 2 through 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an implant 
supported crown (D6066). 
 
You asked the Plan to pre-approve the custom fabricated abutment and implant supported crown. You say that 
an implant was surgically placed last year, and an abutment and crown are needed in order to complete the 
procedure. The Plan denied your request. The Plan says these services are not covered under the enrollee's 
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 a 
custom fabricated abutment (D6057) and an implant supported crown (D6066).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on June 2, 2020. 
 
You asked the Plan to pay for the laboratory testing. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 
laboratory testing. 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 laboratory testing provided on June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair (K0842) and accessories (E2311, 
K0862, E1007). 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you do not fit in your 
current chair. The Plan denied your request. The Plan says the need for a new wheelchair is not documented. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement of equipment due to irreparable 
wear takes into consideration the reasonable useful lifetime of the equipment., which can be no less than 5 
years. The rules also show that  a power mobility device is covered only if the  beneficiary's weight is less than 
or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight 
capacity of the next lower weight class POV. 
 
We looked at the file and Medicare rules. The record shows that your current wheelchair is less than five years 
old and the records do not show it is irreparably damage. Furthermore, the wheelchair you have requested has a 
weight capacity 301 to 450 pounds. The record does not show that your weight is appropriate for this 
wheelchair. Based on this information, we decided that Medicare rules for coverage of a power wheelchair and 
accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power 
wheelchair (K0842) and accessories (E2311, K0862, E1007).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve the portable oxygen concentrator. You say that the portable oxygen 
concentrator is medically necessary. The Plan denied your request. The Plan says the requested portable 
oxygen concentrator is for use outside the home. The plan has already provided home oxygen equipment. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by the 
requested provider. 
 
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says 
the enrollee must receive care from in-network providers with the exception of emergency or urgent care, 
dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network 
provider, which requires prior authorization from the plan. 
 
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 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 physical 
therapy services to be provided by the requested provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two endosteal implants (D6010 x2) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the endosteal implants and complete mandibular denture. You say that the 
realigned dentures will not help you. You also say that you need the implants so that your dentures can be 
screwed in, which will prevent you from choking. The Plan denied your request. The Plan says endosteal 
implant is not a covered benefit. The Plan also says that the complete mandibular denture exceeds the 
maximum count allowed per period. 
 
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, endosteal implant is not among those 
covered under this benefit. The contract lists complete mandibular denture (D5120) as a covered benefit, and is 
limited to one procedure every five plan years. The record shows that you received a complete mandibular 
denture (D5120) on April 21, 2017, and your complete mandibular denture (D5120) benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve two endosteal implants (D6010 
x2) and a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required and 
endodontic therapy to be rendered by an OON provider. 
 
You asked the Plan to pre-approve the core buildup and endodontic therapy. The Plan denied your request. The 
Plan says the provider that was requested to receive these services from is not listed as a contracted provider 
with your plan. The Plan also says that no benefits are available for procedures performed by OON providers. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a core 
buildup, including any pins when required and endodontic therapy to be rendered by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee arthroscopy (CPT Code 29881, CPT Code 29876 
and CPT Code 29877). 
 
You asked the Plan to pre-approve the knee arthroscopy. You say that this surgery is necessary due to a lot of 
knee pain not allowing you to walk very well and that it will possibly get worse. The Plan denied your request. 
The Plan says CMS determines that the following procedures are not considered reasonable or necessary in 
treatment of the osteoarthritic knee and are not covered by the Medicare program. 
 
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 arthroscopy. Our physician 
reviewer found that this enrollee presents with complaints of right knee pain with associated stiffness and 
popping. Clinical exam findings are consistent with imaging evidence of complex medial meniscus tear and 
tricompartmental osteoarthritis, moderate to severe in the medial compartment. The enrollee has failed to 
sufficiently improve despite activity modification, medications, cortisone injection, Euflexxa injections, and 
home exercise program. Under consideration is a request for right knee arthroscopic partial medial 
meniscectomy, chondroplasty, and synovectomy. Medicare coverage criteria states that that the clinical 
effectiveness of arthroscopic lavage and arthroscopic debridement for the severe osteoarthritic knee has not 
been verified by scientifically controlled studies. In the setting of severe osteoarthritis as documented in the 
medical records, this enrollee would not meet the Medicare requirements for the requested surgery. 
 
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 arthroscopy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve knee arthroscopy (CPT Code 29881, CPT Code 29876 and CPT Code 29877).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested lumbar-sacral orthosis (CPT L0637). 
 
You asked the Plan to pre-approve the lumbar-sacral orthosis (CPT L0637). The Plan denied your request. The 
Plan says the Plan has network providers that can appropriately care for the member. 
 
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 item at issue in this appeal. We found no exception that would require the Plan 
to pre-approve this item. Therefore, we decided that the Plan does not have to pre-approve the requested 
lumbar-sacral orthosis (CPT L0637).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pull up adult disposable diapers. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need these because of your 
incontinence. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
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 pull up adult disposable diapers.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for out-of-network lab work. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee is seeking to obtain lab work from a non-participating laboratory. 
 
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 referral for out-of-network lab work.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom fabricated abutments (D6057) and abutment 
supported porcelain fused to metal crowns (D6059) for teeth # 2, 3 and 15. 
 
You asked the Plan to pre-approve the dental services. You say that the Plan had previously paid for implants 
for teeth # 2 and 3. You say that since the implants have been placed, to consider applying the benefit towards 
the restoration. You also say that the enrollee needs help due to a financial hardship. The Plan denied your 
request. The Plan says the requested dental services are not listed as covered 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested custom fabricated 
abutments and abutment supported porcelain fused to metal crowns are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pre-approve custom fabricated abutments (D6057) 
and abutment supported porcelain fused to metal crowns (D6059) for teeth # 2, 3 and 15.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee can safely receive the services you need in other settings. 
 
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. There 
is no evidence of medical issues that require monitoring by an inpatient rehab physician three times a week. 
The documentation does not support that there is a need for an intensive therapy program with 3 hours a day 
and an interdisciplinary approach to rehab care. The enrollee's rehab needs can be met in an alternate, less 
intense setting. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
IRF care. 
 
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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cochlear implant (69930, L8614). 
 
You asked the Plan to pre-approve the cochlear implant. You say that the cochlear implant is medically 
necessary. The Plan denied your request. The Plan says rules for coverage are not met. 
 
The Plan follows Medicare rules. Medicare rules say that cochlear implants 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 cochlear implant. Our reviewer says 
that the cochlear implant hearing aid is not medically necessary. Our physician reviewer found records show 
that the degree of hearing loss is not to the degree that would typically qualify for a cochlear implant and that 
hearing would not be restored to normal even with the implant. 
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 cochlear implant have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cochlear implant (69930, L8614).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions to be performed by an oral surgeon. 
 
You asked the Plan to pre-approve the extractions. You say that you need to have your teeth extracted so you 
can get dentures. The Plan denied your request. The Plan says your contract only covers dental services when 
they are performed by a participating general dentist. The Plan also says that dental services performed by an 
oral surgeon are not covered. 
 
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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve extractions to be performed by an oral surgeon.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled services can be provided at a lower level of care. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require 
intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as 
physical and occupational therapy but the documentation does not support that you require an intensive 
rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not 
meet Medicare criteria for IRF care. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on February 4, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented. 
 
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 
laboratory services. 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 laboratory services provided on February 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve adult sized disposable incontinence product, protective 
underwear/pull-on (T4527). 
 
You asked the Plan to pre-approve incontinence supplies. You say that this was covered by your old plan and 
this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
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 adult sized disposable 
incontinence product, protective underwear/pull-on (T4527).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a routine eye exam. 
 
You asked the Plan to pre-approve the routine eye exam. You say that you are entitled to a good eye exam and 
it is not your fault that your exam was incorrectly performed. The Plan denied your request. The Plan says there 
is no benefit for an additional routine eye exam. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 
these services up to 1 routine eye exam per year. 
 
We looked at the file and the Plan's rules. The file shows that you received a routine eye exam on March 9, 
2020 and you have exhausted the routine eye exam benefit for 2020. Therefore, we decided that the Plan does 
not have to pre-approve a routine eye exam.