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

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5225). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you would like to appeal this 
service based on need and health. The Plan denied your request. The Plan says this 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, maxillary dentures are limited to one 
procedure every five plan years. The record shows that you received a maxillary partial denture on April 16, 
2018, and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not 
have to pre-approve a maxillary partial denture (D5225).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a receiver (monitor) and supply allowance for a 
therapeutic continuous glucose monitor (cgm). 
 
You asked the Plan to pre-approve a receiver (monitor) and supply allowance. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
receiver (monitor) and supply allowance have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a receiver (monitor) and supply allowance for a therapeutic continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Endovenous ablation. 
 
You asked the Plan to pre-approve Endovenous ablation (36475). You say that the enrollee needs endovenous 
ablation. Plan denied your request. The Plan says clinical records were requested but not received.  
 
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. There are no records to support medical necessity of the requested 
procedure. Based on this information, we decided that Medicare rules for coverage of Endovenous ablation 
(36475) have not been met. Therefore, we decided that the Plan does not have to pre-approve Endovenous 
ablation.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional in office fluoroscopic guided bilateral 
radiofrequency ablations (64635, 64636, 77003). 
 
You asked the Plan to pre-approve radiofrequency ablations. You say that it makes no rational sense to 
authorize the preliminary injection and then deny the follow up. The Plan denied your request. The Plan says 
this request cannot be covered as it does not meet medical necessity criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  We looked at this the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of radiofrequency ablations have not been met. Therefore, we decided 
that the Plan does not have to pre-approve two additional in office fluoroscopic guided bilateral radiofrequency 
ablations (64635, 64636, 77003).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture and complete mandibular 
denture. 
 
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say 
that these dentures are medically necessary because you can barely eat. The Plan denied your request. The Plan 
says these services are not covered under your 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 
complete maxillary denture and complete mandibular denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554). 
 
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose 
monitor is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that glucose monitors and supplies are covered when 
the enrollee is insulin-treated with multiple (three or more) daily injections of insulin. 
 
We looked at the file and Medicare rules. The record does not show that the enrollee injects insulin daily. 
Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(K0553, K0554).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom unloader knee brace. 
 
You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee does not have a knee contracture or knee instability. 
 
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 brace. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided there is no documentation that the enrollee requires a custom 
fabricated knee orthosis - there is no documentation of right knee joint laxity or instability. 
 
 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a custom unloader knee brace.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve a transthoracic echocardiogram 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 that the utilization of an echocardiogram for obstructive sleep apnea is not an indication. 
 
The Plan must follow Medicare rules. Medicare rules say that transthoracic echocardiogram can be covered for 
pulmonary disease.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is diagnosed with sleep apnea requiring CPAP therapy. This is considered pulmonary 
disease. In addition, evaluation of right heart function and pulmonary artery pressures (using the tricuspid 
doppler jet) by echocardiography in a patient with sleep apnea is both reasonable and medically necessary. This 
meets both CMS rules criteria (pulmonary disease) and medical necessity as well. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve a transthoracic echocardiogram 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve treatment with an out-of-network, out-of-area provider. 
 
You asked the Plan to pre-approve out-of-area treatment. You say that the enrollee was not diagnosed with his 
condition until after he left the Plan's service area, and a state of emergency prevents him from returning to the 
Plan's service area to receive care at this time. The Plan denied your request. The Plan says that the denial of 
authorization for these services is correct, because this provider is out-of-network with the Plan and the 
enrollee can be treated by an in-network provider. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and 
pre-approved care.   
 
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 out-of-area treatment. Our reviewer 
says that the enrollee meets the Medicare criteria for treatment with an out-of-network, out-of-area provider. 
Our physician reviewer found the enrollee could not have foreseen requiring these services prior to leaving the 
Plan's service area. These services are medically necessary. Due to the unforeseen circumstances of the 
enrollee's current environment, it is against recommendations by the Centers for Disease Control and 
Prevention (CDC) as well as most state and local guidelines. Given the age of the enrollee, he is a particularly 
high risk for travel. It would not be medically reasonable to delay the services until the enrollee is able to return 
to the Plan's service area. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of out-of-area treatment have been met. Therefore, we decided that the Plan has to 
pre-approve treatment with an out-of-network, out-of-area provider.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a folding powered wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says a group 2 power wheelchair is the most appropriate request in this case. 
 
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.  
 
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 wheelchair. Our reviewer says that 
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation is not clear that you would be able to safely operate a folding power wheelchair, but you are 
able to safely operate a Group 2 power wheelchair per the DME consulting evaluation. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a folding powered wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hip arthroscopy. 
 
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 the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has complaints of bilateral 
anterolateral hip pain, worsening over the last several years. There is imaging evidence of possible labral tear. 
She has reportedly failed conservative treatment. Under consideration is a request for right hip joint 
preservation arthroscopic surgery (including femoral osteoplasty, rim trimming and labral repair). She has been 
approved for hip arthroscopy with labral repair. In this case, there is no clear radiographic or imaging evidence 
of CAM or pincer impingement documented by the radiologist to support additional procedures at this time. 
Therefore, the requested hip arthroscopy would not be considered the standard of care or medically reasonable 
and necessary for treatment of the enrollees medical 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hip arthroscopy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a Group 3 power wheelchair and accessories. 
 
You asked the Plan to provide a Group 3 power wheelchair and accessories. You say that because of medical 
issues you need a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says the 
notes do not show you have any of the conditions of criteria. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or 
 
3. Congenital skeletal deformity. 
 
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or 
congenital skeletal deformity. Therefore, we decided that the Plan does not have to provide a Group 3 power 
wheelchair and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown and core buildup, including any pins when 
required provided on August 27, 2020. 
 
You asked the Plan to pay for the crown and core buildup. You say that you cannot afford these charges. The 
Plan denied your request. The Plan says these services are not covered. The Plan also says you did not purchase 
any additional dental coverage. 
 
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 the crown 
and core buildup, including any pins when required provided on August 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex Superion Spacer. 
 
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 the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a history of back pain. 
The requested Superion spacer is considered experimental in nature, as more research is needed to show safety 
and efficacy. The services are therefore not reasonable or medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Vertiflex Superion Spacer.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 6, 2020. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the 
laboratory specimen was obtained in a laboratory, however the submitted medical documentation and/or claim 
history indicates that the specimen was obtained in an office setting. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, the record indicates that the specimen was 
obtained in an office setting, but the claim was billed with a laboratory place of service code. Therefore, we 
decided that the Plan does not have to pay for the laboratory services provided on May 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve primary closure of sinus perforation #15 (D7261) bone 
replacement graft for ridge preservation-per site #15 (D7953). 
 
You asked the Plan to pre-approve the dental services. You say that you have been waiting months to even be 
seen by the doctor. The work needs to be done per the doctor. The Plan denied your request. The Plan says 
these services are 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. The health plan contract 
specifically says any services not listed is not covered by the plan. 
 
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 
primary closure of sinus perforation #15 (D7261) bone replacement graft for ridge preservation-per site #15 
(D7953).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electrical connection controller component (E2311) 
and swing-away hardware (E1028). 
 
You asked the Plan to pre-approve an electrical connection controller component and swing-away hardware. 
You say that these items are needed. The Plan denied your request. The Plan says the criteria for coverage of 
these items has not been met and the enrollee can control the power options with their own switches. 
 
The Plan follows Medicare rules. Medicare rules say that electrical connection controller components and 
swing-away hardware are covered when medically necessary according to the above criteria. 
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 an electrical connection controller 
component and swing-away hardware. Our reviewer says that the criteria for coverage of these items have not 
been met. Our physician reviewer found the expandable harness (E2313) is not medically necessary.  The 
documentation does not reveal that the patient needs an expandable controller to operate other types of 
proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, 
etc.), non-proportional input devices (e.g., sip and puff, head array, etc.), or to operate three or more powered 
seating actuators through the drive control. The documentation does not reveal the patient needs the expandable 
controller to operate a separate display (i.e., for alternate control devices),other electronic devices (e.g., control 
of an augmentative speech device or computer through the chair's drive control), or for an attendant control. 
The patient has sufficient upper extremity strength and functional ability to operate any power options through 
their own individual switches. The swing-away hardware was requested with a wheelchair tray and is therefore 
not covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electrical connection controller component and swing-away hardware have 
not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical connection 
controller component (E2311) and swing-away hardware (E1028).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided to the enrollee on June 25, 2020 and 
July 7, 2020. 
 
You asked the Plan to pay for the visit. You say that these claims were processed in error. The Plan denied your 
request. The Plan says no provider or supplier shall receive payment for services furnished to a Medicare 
beneficiary unless the provider or supplier is enrolled in the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for an office 
visit provided to the enrollee on June 25, 2020 and July 7, 2020.