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

We decided that the Plan does not have to pre-approve the insertion of Dextenza (0356T). 
 
You asked the Plan to pre-approve Dextenza. You say that this is covered by Medicare. The Plan denied your 
request. The Plan says this is experimental. 
 
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 Dextenza. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found Dextenza is a drug-eluting intracanalicular ophthalmic insert used for the treatment of ocular 
inflammation and pain following ophthalmic surgery. The device may be appropriate patients with physical or 
mental limitations which make drop-use challenging, patients at higher risk for inflammation such as those 
with uveitis, and patients with severe dry eyes. In general, topical steroid or NSAID drops are used for 
postoperative inflammation after cataract surgery. In this case, there is no specific indication as to why 
Dextenza is used over the standard postoperative drops.  Therefore, there is no medically necessity for the use 
of this 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 Dextenza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the insertion of Dextenza (0356T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you may 
benefit from chronic BiPAP support at night. Medicare does not cover a ventilator when used as BiPAP, and 
certain BiPAP devices are capable of providing the AVAPS-AE mode of support. BiPAP failure has not been 
demonstrated in the home setting.  A home ventilator is not 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 the ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a portable ventilator for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 9 extractions (D7140) and a complete lower denture 
(D5120). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says dentures are not listed as a covered service. The Plan also says the requested 
extractions are not specifically listed as 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 9 
extractions (D7140) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three surgical extractions of erupted teeth, gingival 
irrigation, alveoplasty. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this 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 three 
surgical extractions of erupted teeth, gingival irrigation, alveoplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6752) for teeth # 17, 20 and 21, and 
pontics (D6242) for teeth # 18 and 19. 
 
You asked the Plan to pre-approve the dental services. You say that the Summary of Benefits says up to 8 fixed 
bridge units per tooth per year are covered. You say that you still have not reached the limit. The Plan denied 
your request. The Plan says up to 8 fixed bridge units (pontics and retainers) per year are covered. The Plan 
says that the frequency limit has been reached. 
 
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 and fixed bridges are a covered service, 
the frequency limit of up to 8 units per year has been exceeded. The record shows that the Plan previously 
approved retainer crowns for teeth # 2, 5, 6, 29 and 31, and pontics for teeth # 3, 4 and 30. Therefore, we 
decided that the Plan does not have to pre-approve retainer crowns (D6752) for teeth # 17, 20 and 21, and 
pontics (D6242) for teeth # 18 and 19.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of intraspinous lumbar decompression device 
(22869 and 22870). 
 
You asked the Plan to pre-approve insertion of intraspinous lumbar decompression device. You say that you 
are in a lot of pain. This is medically necessary and you don't understand why this would get denied. The Plan 
denied your request. The Plan says the requested procedure is not reasonable or medically necessary at this 
time. 
 
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 insertion of intraspinous lumbar 
decompression device. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research 
is needed to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of intraspinous lumbar decompression device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve insertion of intraspinous lumbar 
decompression device (22869 and 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator trial. 
 
You asked the Plan to pre-approve a spinal cord stimulator trial. You say that you are in excruciating pain and 
in need of a spinal cord stimulator trial. The Plan denied your request. The Plan says the records do not indicate 
that surgery was considered or that you were deemed not to be a surgical candidate. 
 
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 does not show surgical modality has been tried or 
contraindicated for you. Based on this information, we decided that Medicare rules for coverage of a spinal 
cord stimulator trial have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
spinal cord stimulator trial.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urology services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the enrollee is continuing care since 2018. The 
Plan denied your request. The Plan says the enrollee can be treated by a contracted 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
urology services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stationary bicycle. 
 
You asked the Plan to pre-approve a stationary bicycle. You say that a stationary bicycle will improve the 
enrollee's musculoskeletal system for qualify of life. The Plan denied your request. The Plan says exercise 
equipment is statutorily not covered. 
 
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 stationary bicycle.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hetlioz cap 20mg for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this medication falls under Part D coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hetlioz cap 20mg for the 
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on May 24, 2020. 
 
You asked the Plan to pay for the testing services. You say that the testing was ordered to determine if there 
was a more effective therapy to treat the enrollee's advanced cancer. The Plan denied your request. The Plan 
says the bulk of the panel is not relevant to the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. We find that the testing at issue was not billed with the appropriate CPT 
code or DEX Z-Code, per billing guidance. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 
testing provided on May 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair. 

You asked the Plan to pre-approve a manual wheelchair. You say that the enrollee needs a manual wheelchair. 
The Plan denied your request. The Plan says the documentation submitted make no mention of the enrollee's 
need for a manual wheelchair or any mobility issues. 
 
The Plan follows Medicare rules. Medicare rules say that a manual wheelchair will not be covered if the patient 
does not have mobility deficit that impairs their participation in MRADLs, or the patient's condition can be 
ameliorated by a walker or cane, or the enrollee's home does not provide adequate access for use of the manual 
wheelchair. 
 
The file does not show that the enrollee has a mobility deficit that impairs their participation in MRADLs, or if 
their condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for 
coverage of a manual wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a manual wheelchair.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided to the 
enrollee from March 11, 2020, to April 2, 2020. 
 
You asked the Plan to pay for the SNF care. The Plan denied your request. The Plan says the enrollee no longer 
required skilled care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 pay for the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the enrollee did not have documented 
skilled nursing needs. The enrollee did not have documented skilled therapy needs.  Daily skilled services were 
not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The 
enrollee's care needs, as a practical matter, could be provided at a lower level of 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 the SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided to the enrollee from March 11, 2020, to April 2, 
2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomographic colonography (74263). 
 
You asked the Plan to pre-approve the colonography. You say that this procedure is less invasive and has less 
risk than a standard colonoscopy and should be covered. The Plan denied your request. The Plan says this is not 
a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Screening computed tomographic colonography 
(CTC) is non-covered.  
 
We looked at the file and Medicare rules. The requested colonography is not a covered service. Based on this 
information, we decided that Medicare rules for coverage of the colonography have not been met. Therefore, 
we decided that the Plan does not have to pre-approve a computed tomographic colonography (74263).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 72170) provided on January 23, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 
billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that some ICD-10-CM codes indicate laterality, 
specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the 
condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the 
medical record, assign the code for the unspecified side. 
 
We looked at the file and Medicare rules. The service in question were billed with left and right diagnosis 
codes. However, since a bilateral code exists, this code should have been used in lieu of the separate left and 
right codes. Based on this information, we decided that Medicare rules for coverage of the services have not 
been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 72170) provided on 
January 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP battery kit (E1399). 
 
You asked the Plan to pre-approve the battery kit. You say that you would like reconsideration because a 
backup battery is needed due to electric power problems. The Plan denied your request. The Plan says the 
backup batters is not covered by Medicare. 
 
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 CPAP full face mask. a CPAP full face mask serves the same purpose as the 
battery kit. Therefore, we decided that the Plan does not have to pre-approve a CPAP battery kit (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core in addition to a crown 
(D2954) and a crown (D2740). 
 
You asked the Plan to pre-approve the prefabricated post and core in addition to a crown. The Plan denied your 
request. The Plan says prefabricated post and core in addition to a crown is not listed as 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 items or services are not 
among those covered under this benefit. The dental handbook clearly states that if a dental item or service is 
not listed in the benefit chart then it is not covered. Therefore, we decided that the Plan does not have to pre-
approve a prefabricated post and core in addition to a crown (D2954) and a crown (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 prefabricated abutments (D6056), an adjunctive pre-
diagnostic test (D0431), an abutment supported removable upper denture (D6110), and an abutment supported 
removable lower denture (D6111). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee is not able to use dentures. The 
Plan denied your request. The Plan says the requested dental services are not listed as covered services. The 
Plan also says any services not listed 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 
among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pre-approve 6 prefabricated abutments 
(D6056), an adjunctive pre-diagnostic test (D0431), an abutment supported removable upper denture (D6110), 
and an abutment supported removable lower denture (D6111).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home elevator. 
 
You asked the Plan to pre-approve the elevator. You say that this is medically necessary. The Plan denied your 
request. The Plan says an elevator of any kind 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 a home elevator.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee is receiving adequate and necessary intensive rehabilitation 
in the Inpatient Rehabilitation Facility. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 bone replacement grafts (D4263). 
 
You asked the Plan to pre-approve the dental service. You say that you have a severe sinus infection. You say 
that the infection bore a hole in your sinus cavity and you need to have a bone graft before an extraction can be 
done. You also say that the infection will not go away unless the tooth is pulled out. The Plan denied your 
request. The Plan says bone replacement graft is not listed as a covered service. The Plan also says any services 
not listed 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 
among those covered under this benefit. The Evidence of Coverage clearly states that any services not listed are 
not covered. Therefore, we decided that the Plan does not have to pre-approve 2 bone replacement grafts 
(D4263).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron. 
 
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 self-administered drugs are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.  
 
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.