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

 
We decided that the Plan does not have to provide additional reimbursement for the walker purchased on April 
22, 2020. 
 
You asked the Plan to provide additional reimbursement for the walker. You say that you purchased this item 
online because you feel that the provider offered by the Plan was going to charge too much. You feel that you 
should receive the full amount that you paid. The Plan denied your request. The Plan says you were reimbursed 
the correct amount which is the Medicare allowable fee for this item. 
 
The Plan must follow Medicare rules. Medicare rules say that noncontract Medicare providers must accept the 
Medicare allowable as payment in full.  
 
In this case, you received this item from a provider that is not enrolled in Medicare. This provider is not 
required to accept the Medicare payment as payment in full; however, the plan is not obligated to pay more 
than this amount for the covered item. Therefore, we decided that the Plan does not have to provide additional 
reimbursement for the walker purchased on April 22, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the chiropractic manipulation. We decided that the Plan does not have 
to pay for the other services provided by the chiropractor.  
 
You asked the Plan to pay for the chiropractic manipulation. You say that you were not told what was and was 
not covered and were informed that there was only a $20 copayment. The Plan says that these are not covered 
services. 
 
We decided that the Plan has to pay for the chiropractic manipulation.  
 
The Plan follows Medicare rules. Medicare rules say that manual manipulation of the spine is a covered 
service. The contract says that this carries a $20 copayment. 
 
In this case, the Plan failed to provide any information which would justify denial of the manual manipulation 
(98941) provided by the in-network chiropractor. There is no evidence presented that there was a lack of spinal 
subluxation or that 12 visits had been provided for the year, which would have required prior authorization. 
The denial of payment is not supported. Therefore, we decided that the Plan has to pay for the chiropractic 
manipulation.  
 
We also decided that the Plan does not have to pay for the other services provided by the chiropractor. 
 
The Plan follows Medicare rules. Medicare rules say that the only chiropractic service covered by Medicare is 
manual manipulation. Your contract clearly states that other services are not covered. Therefore, we decided 
that the Plan does not have to pay for the other services provided by the chiropractor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve disposable pads and undergarments. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you do not agree with this denial. The 
Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve disposable pads and 
undergarments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up services. 
 
You asked the Plan to pre-approve core build up 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 pre-approve core 
build up services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound received on June 8, 2020. 
 
You asked the Plan to waive the copayment for the ultrasound. You say that you are appealing the $40 
copayment The Plan denied your request. The Plan says the copayment was applied correctly according to your 
benefits and the services rendered. 
 
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 $40 
copayment for basic imaging services.  
 
You have been asked to pay a $40 copayment for the ultrasound. The ultrasound falls within the basic imaging 
services benefit category. This means that you have been 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 ultrasound received on 
June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three bilateral levels of facet nerve neurolysis 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 the request is for three levels bilaterally, and this exceeds the maximum number of 
levels covered. 
 
The Plan must follow Medicare rules. Medicare rules say that only two bilateral levels/four unilateral levels 
may be done per session of facet nerve neurolysis. 
 
The requested service is to be done at three levels, which exceeds the Medicare-allowed limit. 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 pre-approve three bilateral levels of facet nerve neurolysis for the 
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve relaxation gas 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 to qualify for this benefit, the approved treatment must include four or more extractions 
and/or significant restorative work. 
 
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 services 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
submitted did not indicate any reason for the need for nitrous oxide analgesia. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve relaxation gas for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the out-of-network office visit. You say that you would like reconsideration 
because this provider has been monitoring your worsening condition. The Plan denied your request. The Plan 
says you can get medically needed care from a doctor that is not in your primary network if a network doctor is 
not able to provide care or you have an emergency. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion office visit (99203) for surgical 
evaluation to be rendered by the out of network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says there are in-network providers available to render this 
service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a second 
opinion office visit (99203) for surgical evaluation to be rendered by the out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve knee arthroscopy (29880). 
 
You asked the Plan to pre-approve the knee arthroscopy. You say that you would like reconsideration because 
this procedure is medically necessary. The Plan denied your request. The Plan says that the member does not 
meet Plan criteria for failure of at least 3 months of knee pain with loss of function, failure of at least 6 weeks 
of non-operative treatment or MRI findings of an unstable tear. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the knee arthroscopy. Our reviewer 
says that the requested items/services are considered medically reasonable and necessary in this case. Our 
physician reviewer found current evidence based medical literature supports surgical intervention at this time 
based on progressive subjective complaints, physical exam, imaging findings, and failed conservative 
treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the knee arthroscopy have been met. Therefore, we decided that the Plan has to 
pre-approve knee arthroscopy (29880).  
 
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 power operated wheelchair (K0801). 
 
You asked the Plan to pre-approve the wheelchair. You say that you would like reconsideration because this 
wheelchair is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare 
coverage 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 wheelchair. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation does not support that your mobility limitation cannot be sufficiently and 
safely resolved by the use of an appropriately fitted cane or walker or manual wheelchair and that you can 
safely maneuver the requested wheelchair in the home. The documentation does not indicate that  your home 
provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is 
provided. 
 
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 power operated wheelchair (K0801).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve basivertebral radiofrequency ablation. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary for unresolved low 
back pain in spite of multiple treatments. The Plan denied your request. The Plan says there is insufficient 
evidence to support the effectiveness and safety for this procedure. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is an experimental and investigational procedure at this time. Therefore, the request is not considered 
medically reasonable and 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve basivertebral radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric reclining sit to stand chair.
You asked the Plan to pre-approve the chair. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
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 an electric reclining sit to stand chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair for your mother. 
 
You asked the Plan to pre-approve a shower chair. You say that your mother needs a shower chair after 
returning from rehab. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair for your mother.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pontic (D6240) and retainer crown (D6750). 
 
You asked the Plan to pre-approve the pontic (D6240) and retainer crown (D6750). You say that you were 
informed dental implants were covered. You say that the guarantee of success was much higher for 
bridgework. The Plan denied your request. The Plan says the services are not covered 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. 
 
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 
pontic (D6240) and retainer crown (D6750).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Feraheme.
You asked the Plan to pre-approve Feraheme. You say that the requested Feraheme is medically necessary. The
Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested Feraheme.
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 Feraheme. Our reviewer says that the
requested Feraheme is medically necessary. Our physician reviewer found the enrollee is diagnosed with
hemophilia, anemia, iron deficiency disorder, irregular heartbeat, osteopenia, osteoporosis, and thrombocytosis.
This enrollee has multiple reasons why systemic absorption of iron is unlikely to be adequate including
advanced age and use of proton pump inhibitor. Prior oral iron has been shown to ineffective. The use of
parenteral iron with feraheme is reasonable and 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 Feraheme have been met. Therefore, we decided that the Plan has to preapprove
Feraheme.
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 shoe inserts (L3020).
You asked the Plan to pre-approve shoe inserts. You say that you have had inserts covered in the past. 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 shoe inserts (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the overdenture, surgical implant placements, custom 
fabricated abutments and abutment supported crowns. 
 
You asked the Plan to pre-approve the overdenture, surgical implant placements, custom fabricated abutments 
and abutment supported crowns. You say that you have been in constant pain and having trouble eating. You 
say that your health will be affected without the services. The Plan denied your request. The Plan says the 
services are not covered 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. 
 
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 
overdenture, surgical implant placements, custom fabricated abutments and abutment supported crowns.
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 you have a callus, with flat feet and a wide 
instep. The Plan denied your request. The Plan says your history is negative for diabetes, and you do not wear a 
leg brace. 
 
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 endodontic therapy (root canal) of a molar tooth. 
 
You asked the Plan to pre-approve dental service. You say that a Plan representative told you that this 
procedure was covered. The Plan denied your request. The Plan says the denial of authorization for this service 
is correct, because endodontic therapy of the requested molar tooth is not covered by the 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 
endodontic therapy (root canal) of a molar tooth.