Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endoscopic decompression of the spinal cord. 
 
You asked the Plan to pre-approve the endoscopic spinal procedure. You say that this procedure would be the 
best option for the enrollee. The Plan denied your request. The Plan says this procedure is not considered 
medically necessary as it is investigational. 
 
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 endoscopic spinal procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found endoscopic lumbar discectomy remains experimental. More research is needed 
to show the safety and efficacy of the procedure. It is not the gold standard procedure and not shown to be 
superior to open discectomy. 
 
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 endoscopic spinal procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve endoscopic decompression of the spinal cord.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6212) for tooth #'s 11, 12, 13, & 14 and 
retainer crowns (D6752) for tooth #'s 11, 12, 13, & 14. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you need the bridges because 
you are having trouble eating. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the pontics 
and retainer crowns when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the pontics and retainer crowns. Our 
reviewer says that the services do not meet coverage criteria. Our physician reviewer found a review of the 
enrollee's dental record and x-rays indicate the presence of a defective fixed bridge replacing tooth #12 using 
tooth #'s 11 and 14 as abutment retainers. Our reviewer also found that the space (tooth #'s 12 and 13) has 
closed somewhat, and only one pontic would be needed to fill the area, as was done with the existing bridge. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6212) for tooth #'s 11, 12, 13, & 14 and retainer crowns 
(D6752) for tooth #'s 11, 12, 13, & 14.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection for power wheelchair. 
 
You asked the Plan to pre-approve an electronic connection. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that if a wheelchair has an electrical connection 
device described by code E2310 or E2311 and if the sole function of the connection is for a power seat 
elevation or power standing feature, it will be denied as non-covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an electronic connection have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an electronic connection for power wheelchair.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Neulasta (J2505). 
 
You asked the Plan to pre-approve Neulasta. You say that Neulasta is medically necessary. The Plan denied 
your request. The Plan says that coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Neulasta. Our reviewer says that 
Neulasta is medically necessary. Our physician reviewer found Neulasta is FDA approved for the treatment of 
neutropenic fever in patients receiving chemotherapy with a risk of neutropenic fever of >20%. The 
chemotherapy regimen of carboplatin and paclitaxel with the additional risk factors of the patient's age and 
recent surgery put her risk of neutropenic fever at >20%. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have been met. Therefore, we decided that the Plan has to pre-approve 
Neulasta (J2505).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a rest of your vision benefits. 
 
You asked the Plan to pre-approve the reset. You say that your progressive lenses are not correct, and you 
cannot see with them. The Plan denied your request. The Plan says the provider is willing to correct any issues 
that you are having. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when progressive lenses with a limit of up $150 per year. 
 
We looked at the file and the Plan's rules. You have already maximized the benefit for progressive lenses, so 
you are not allowed to receive new ones. However, the file shows that the provider is willing to work with you 
to fix anything with the lenses that needs correction. Based on this information, we decided that the Plan's rules 
for coverage of the reset have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
rest of your vision benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reaching/grabbing device. 
 
You asked the Plan to pre-approve a reaching/grabbing device. You say that you need this because you have 
difficulty picking up objects. The Plan denied your request. The Plan says that this is not covered by Medicare. 
 
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 reaching/grabbing device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that these are necessary. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown and a post and core in addition to crown. 
 
You asked the Plan to pre-approve the crown and post and core. You say that the sales agent advised that as of 
January 1, 2020 you would have coverage for dental services. The Plan denied your request. The Plan says 
these services are not covered benefits 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 
crown and a post and core in addition to crown.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the removal of torus mandibularis (D7473). You say that you have a broken 
tooth and its causing pain. You say that the surgery is very much needed. 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 the 
removal of torus mandibularis (D7473).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete maxillary and mandibular dentures. You say that your face has 
been disfigured from the cancer treatment, and you have been without dentures because of the treatment. The 
Plan denied your request. The Plan says these services exceed 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, complete maxillary denture (D5110) 
and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record 
shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on 
April 4, 2018 and your complete maxillary denture and complete mandibular denture benefits have been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture 
(D5110) and a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two endosteal implants (D6010 x2). 
 
You asked the Plan to pre-approve the endosteal implants. You say that the enrollees current bone height and 
density is at a good level to have two implants placed. You also say that due to the enrollee's past medical 
history, and previously lost bone, there is a chance that this would be one of the final years that he could be a 
candidate for implants. The Plan denied your request. The Plan says this service is not a covered benefit 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 two 
endosteal implants (D6010 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle. 
 
You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no additional objective information provided to support the need for this. 
 
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 vehicle. Our reviewer says that the 
requested vehicle is not medically reasonable or necessary. Our physician reviewer found there is no 
documentation of a personal mobility deficit that impairs participation in mobility-related activities of daily 
living. There is documentation that your mobility deficit could be helped by the use of a walker. There is no 
documentation that you could safely operate the PMD. 
 
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 vehicle have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power operated vehicle.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lower partial denture (D5214). 
 
You asked the Plan to pre-approve the lower partial denture (D5214). You say that you do not agree with the 
denial and are appealing the decision. The Plan denied your request. The Plan says the service is only covered 
once every 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, the Plan also have a maximum benefit 
of one partial denture every 5 years. The Plan paid for a lower partial denture (D5214) provided on June 1, 
2018, which exhausted the benefit. Therefore, we decided that the Plan does not have to pre-approve the lower 
partial denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a septoplasty (30520). 
 
You asked the Plan to pre-approve a septoplasty. You say that you need this because you were attacked. The 
Plan denied your request. The Plan says the documentation is insufficient to show medical necessity. 
 
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 septoplasty. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found computed tomography scan shows mild deviation of the septum, with patent nasal passages. 
 
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 septoplasty have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a septoplasty (30520).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the test strips. 
 
You asked the Plan to pre-approve the strips. You say that this is medically necessary. The Plan denied your 
request. The Plan says you did not meet the prior authorization criteria. 
 
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 strips. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there needs to be documentation of a failure of the formulary test strip because the non-formulary strips 
can be approved. There is no failure - only a patient preference documented. The insurer has made available an 
approved test strip. 
 
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 strips have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the test strips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the assisted living facility will not take you back 
until you do rehabilitation, and sending you home is not an option. The Plan denied your request. The Plan says 
Medicare coverage criteria have not been met for admission to an acute IRF. 
 
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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that 
your medical status does not currently require intensive physician and nursing oversight only in an IRF. Our 
physician reviewer also found that you may benefit from multiple therapies such as physical and occupational 
therapy, but the documentation does not support that your functional level requires an 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture and a mandibular partial 
denture. 
 
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. The Plan 
denied your request. The Plan says the partial dentures are not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the maxillary 
partial denture and mandibular partial denture. when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the maxillary partial denture and 
mandibular partial denture. Our reviewer says that the dentures are not medically necessary. Our physician 
reviewer found a flexible partial denture in a situation where there are missing posterior teeth distal to the first 
premolar tends to be unstable and would need to be evaluated as to appropriateness. An upper flexible partial 
denture would likely be appropriate on the upper arch if it were clear that the broken abutments were to be 
removed, as it would not be appropriate to fabricate the appliance directly over the broken teeth. Our reviewer 
found that the treatment plan must be presented so that it is clear which teeth are to be removed and which are 
to be replaced in order to properly assess the appropriateness of the proposed treatment. Our physician reviewer 
also found that when the clinical treatment plan is provided for upper and lower arches then a proper review of 
the requests can then be made. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the maxillary partial denture and mandibular partial denture. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture and a mandibular 
partial denture.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
January 27, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says the submitted claim does not include the 
required FIPS code. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
submitted claim does not include the required FIPS code. Therefore, we decided that the Plan does not have to 
pay for the home health services provided to the enrollee from January 27, 2020.