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

 
We decided that the Plan does not have to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve the medial branch blocks. You say that you would like reconsideration 
because this service is medically necessary. The Plan denied your request. The Plan says the records do not 
show that the prior injections were successful. 
 
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 medial branch blocks. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee underwent diagnostic L3 medial branch, L4 medial branch and L5 dorsal 
ramus blockade on 7/17/2020 with a documented improvement of under 80%. The provided medical records do 
not document that the enrollee has satisfied the LCD requirements. 
 
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 medial branch blocks have not been met. Therefore, we decided that the 
Plan does not have to pre-approve medial branch blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve push handles and bag hooks (K0108) a seat elevation 
system (E2300) and seat cushion cover (E2619). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that you would like reconsideration 
because these accessories are medically necessary. The Plan denied your request. The Plan says this equipment 
does not meet the definition of durable medical equipment. 
 
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 push handles and bag hooks (K0108) a seat elevation 
system (E2300) and seat cushion cover (E2619).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve routine transportation. You say that you need to get to dialysis 3 days per week and have no other form of transportation to get to these appointments. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 30 one-way trips per calendar year is not covered by the Plan.
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 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. Additionally, this request does not qualify for the 22 additional trips the Plan covers to certain supplemental benefit locations. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve in-network benefit coverage for medical services to be 
provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the in-network benefit coverage. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says there are network 
providers available who may treat you and there is no documentation of emergent conditions. 
 
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 
in-network benefit coverage for medical services 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 fixed partial denture.
You asked the Plan to pre-approve the fixed partial denture. You say that you explained treatment options and expectations of dentures. You say that the enrollee elected to get treatment. The Plan denied your request. The Plan says the 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, fixed partials are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the fixed partial denture.
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 the PWC. You say that you have a great deal of pain and are not able to do 
activities in your home without pain. You feel that this should be covered because a provider should not be able 
to tell you that you do not need this due to your extreme pain. The Plan denied your request. The Plan says the 
documentation does not show that you cannot use a walker or manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does demonstrate that you have a mobility deficit that impairs your participation in MRADLs in the 
home. However, it does not document that this deficit is not ameliorated by a walker or manual wheelchair. 
This means that Medicare rules for coverage of a PMD 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 other drugs, mouth and face pictures, tooth molds, bone 
graft services, alveoloplasty, and general anesthesia services, additional minutes. 
 
You asked the Plan to pre-approve other drugs, mouth and face pictures, tooth molds, bone graft services, 
alveoloplasty, and general anesthesia services, additional minutes. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve other 
drugs, mouth and face pictures, tooth molds, bone graft services, alveoloplasty, and general anesthesia services, 
additional minutes.
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. The Plan denied your request. The Plan says the 
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 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. We found no exception that would require the 
Plan to pre-approved these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgical procedure. 
 
You asked the Plan to waive the copayment for these services. You say that you disagree with the denial. The 
Plan denied your request. The Plan says the copayment cannot be waived. 
 
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 $350 
copayment per day for outpatient procedures and services performed in an outpatient hospital or ambulatory 
surgical center.  
 
The services at issue are an outpatient surgical procedure in the form of an injection. If you choose to receive 
these services, you will be asked to pay a $350 copayment per day for these services. These services fall within 
the outpatient procedures and services performed in an outpatient hospital or ambulatory surgical center benefit 
category. This means that you will be 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 an outpatient surgical procedure.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a wireless capsule endoscopy. 
 
You asked the Plan to pre-approve the wireless capsule endoscopy. You say that you would like 
reconsideration because this service is medically necessary. The Plan denied your request. The Plan says the 
standard test that the member already completed showed a source of the bleeding. 
 
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 wireless capsule endoscopy. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found endoscopic studies have repeatedly identified and therapeutically addressed 
sources of GI blood loss. As such, the member's GI bleeding is not occult. 
 
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 wireless capsule endoscopy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a wireless capsule endoscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup (D2950). You say that tooth #9 has large decay but can be 
restored with buildup and a crown. The Plan denied your request. The Plan says the 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 core 
buildup (D2950).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by a network 
provider. 
 
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 services 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 partial upper denture and partial lower denture. 
 
You asked the Plan to pre-approve partial upper denture and partial lower denture. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are only 
covered once every 60 months. 
 
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 partial upper 
denture and partial lower denture when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Dentures are covered once every 5 years. You last received dentures 
on November 3, 2016. Five (5) years have not passed since you previously received dentures. Based on this 
information, we decided that the Plan's rules for coverage of partial upper denture and partial lower denture 
have not been met. Therefore, we decided that the Plan does not have to pre-approve partial upper denture and 
partial lower denture.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cologuard test. 
 
You asked the Plan to pre-approve a Cologuard test. You say that because of Covid-19 you do not want to have 
a colonoscopy. The Plan denied your request. The Plan says you do not meet Medicare guidelines for the test. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
  
We looked at the file and Medicare rules. The record shows you are not asymptomatic. Based on this 
information, we decided that Medicare rules for coverage of a Cologuard test have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a Cologuard test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need a portable oxygen 
concentrator for work. The Plan denied your request. The Plan says you currently have portable tanks still 
under reasonable useful lifetime. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The record shows that you have a stationary oxygen system with refillable portable tanks. This portable oxygen 
system meets your in-home needs and serves the same purpose as a portable oxygen concentrator. Your 
portable oxygen system is still under the reasonable useful lifetime and criteria for replacement is not met. 
Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
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 although you test your blood sugar four times a day, 
your insulin treatment regimen does not require frequent adjustment by you on the basis of BGM or CGM 
testing results. Furthermore, you only have two daily injections of insulin, which is less than the requirement of 
at least three daily insulin injections. 
 
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 tests 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 does not show that the enrollee injects insulin at least three or more times per day. 
Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose 
Monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services. 
 
You asked the Plan to pay for core buildup services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested services are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six additional physical therapy visits. 
 
You asked the Plan to pre-approve the additional visits. You say that additional therapy is necessary. The Plan 
denied your request. The Plan says this is 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 the additional 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 based on the medical records provided there is no documentation that 
the six additional requested therapy visits are generally accepted as specific and effective therapy for your 
condition. The six additional visits approved by the health plan should be sufficient to reinforce and finalize a 
home exercise plan for you. 
 
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 additional visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve six additional physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding wheeled walker with seat attachment. 
 
You asked the Plan to pre-approve a folding wheeled walker with seat attachment. You say that you need a 
folding wheeled walker with seat attachment. The Plan denied your request. The Plan says you currently have a 
four wheeled walker with a seat that meets your mobility needs. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a walker with a seat. Your walker serves the same purpose, as the walker at issue. 
The assessment shows your current walker is less than one year old and meets your needs. Therefore, we 
decided that the Plan does not have to pre-approve a folding wheeled walker with seat attachment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental crown for tooth 14. 
 
You asked the Plan to pre-approve a crown (D2740) for tooth 14. You say that it is a necessity that the crown 
goes along with the other procedure. The Plan denied your request. The Plan says the service 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. The Plan covers one crown per 
tooth, every five plan years, when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The record shows a crown procedure for this tooth was done on 
November 10, 2016. Based on this information, we decided that the Plan's rules for coverage of a crown for 
tooth 14 (D2740) have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental 
crown for tooth 14.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physical therapy services. 
 
You asked the Plan to pre-approve the physical therapy services. The Plan denied your request. The Plan says 
the service is not emergent and available within the 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 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 physical therapy services.