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

 
We decided that the Plan has to pre-approve a mandibular partial denture. 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you have never had a lower 
partial denture. The Plan denied your request. The Plan says that this service is allowed one time every 36 
months. The Plan also says that you received this service less than 36 months ago. 
 
The Plan must follow Medicare rules. Medicare rules say that the Plan must provide you with a clear and 
accurate description of the Original Medicare and/or mandatory/optional supplemental benefits offered under 
your plan contract including applicable conditions and limitations and any other conditions associated with the 
use or receipt of the benefits.  
 
We looked at the file and Medicare rules. The contract simply states that dentures, including complete and 
partial dentures, are covered benefits. The provided contract does not clearly show that there is a 36-month 
limitation to the benefit for dentures. Based on this information, we decided that Medicare rules for coverage of 
the mandibular partial denture have been met. Therefore, we decided that the Plan has to pre-approve a 
mandibular partial denture.  
 
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: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to to an out-of-network radiology provider 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are network providers available. 
 
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 
a referral to to an out-of-network radiology provider
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
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 your record does not show that you require daily skilled nursing or 
skilled therapy in a SNF setting. 
 
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 your 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.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve crowns (D2750) for tooth #'s 20 and 21. 
 
You asked the Plan to pre-approve the crowns. The Plan denied your request. The Plan says that the crowns 
were denied due to lack of dental necessity. 
 
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 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 crowns. Our reviewer says that the 
criteria for coverage for crowns (D2750) for teeth #'s 20 and 21 have been met. Our physician reviewer found 
the enrollee's dental record and radiographs indicate the presence of large restorations present in teeth #'s 20 
and 21 with recurrent caries. Our reviewer found that crown restorations are medically reasonable and 
necessary to restore these teeth to adequate masticatory function. 
 
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 crowns have been met. Therefore, we decided that the Plan has to pre-
approve crowns (D2750) for tooth #'s 20 and 21.  
 
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: Testing
Decision: Favorable

 
We decided that the Plan has to pay for the duplex scan of lower extremity arteries or arterial bypass grafts; 
complete bilateral study provided on April 24, 2019. 
 
You asked the Plan to pay for the duplex scan of lower extremity arteries or arterial bypass grafts. You say that 
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services 
were billed with a non-covered diagnosis code. 
 
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 pay for the duplex scan of lower extremity arteries 
or arterial bypass grafts. Our reviewer says that the requested items/services are considered medically 
reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of Diabetes 
mellitus, hypertension, peripheral artery disease (PAD), coronary artery disease, obesity, and hypothyroidism. 
The enrollee has a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of 
Duplex scan of lower extremity arteries or arterial bypass grafts (PAD status post angiogram follow-up). The 
Duplex scan of lower extremity arteries or arterial bypass grafts is considered the standard of care for the 
treatment of this enrollee's condition. 
 
Review of the file shows that the plan uses Local Coverage Article (LCA) A57592 to support their denial. The 
plan states that the LCA has a list of diagnosis codes that support medical necessity of the service provided and 
any diagnosis code not listed is not covered. However, the LCA does not state that any diagnosis code not 
listed is not covered. In addition, this LCA is not valid for the date of service at issue. Therefore, we cannot use 
LCA A57592 to substantiate our decision. 
 
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 duplex scan of lower extremity arteries or arterial bypass grafts have been 
met. Therefore, we decided that the Plan has to pay for the duplex scan of lower extremity arteries or arterial 
bypass grafts; complete bilateral study provided on April 24, 2019.  
 
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: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance service and ground mileage provided on January 18, 
2020, by an OON provider. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that these services were 
rendered due to medical necessity. The Plan denied your request. The Plan says that these services were 
rendered by a non-contracted provider. The Plan also says that the care was not approved in compliance with 
the Medicare Health Plan's authorization procedures. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide a copy of the applicable 2020 Evidence of Coverage 
for this case. Without this information we cannot determine that the Plan's coverage rules support the denial of 
payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. 
Consequently, the Plan has not substantiated their denial of payment in this case. Therefore, we decided that 
the Plan has to pay for the ambulance service and ground mileage provided on January 18, 2020, by an OON 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha SureClick. 
 
You asked the Plan to pre-approve Repatha SureClick. The Plan denied your request. The Plan says this drug is 
not covered for the enrollee's condition by Medicare Part B. 
 
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 Repatha SureClick.  
 
Benefits for Repatha SureClick may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 outpatient office visits (99214 x8 and 99215 x8) to 
be rendered by an OON provider. 
 
You asked the Plan to pre-approve the outpatient office visits. You say that the OON provider you are 
requesting services from has been your neurologist since you had a stroke on January 9, 2018. You also say 
that this provider was highly recommended, and you would like to continue care with them. The Plan denied 
your request. The Plan says the provider you have requested to receive these office visits from is an OON 
provider. The Plan also says that the services can be safely rendered by an in-network provider. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees? needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for 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 the outpatient office visits. Our 
reviewer says that the OON office visits are not medically necessary. Our physician reviewer found you are not 
currently receiving any active treatment and/or medical management of your condition that would require 
continued care with the out-of-network neurologist. Our reviewer found that there are not any unique 
circumstances present in this case that would establish medical necessity for an exception. The Plan has 
identified multiple neurologists (in-network) and local to your residence who can address your condition. Our 
physician reviewer also found that your care can easily and readily be continued on an in-network basis. There 
were no special treatments or interventions being provided that could not otherwise be ordered/rendered by an 
in-network provider. 
 
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 outpatient office visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 16 outpatient office visits (99214 x8 and 99215 x8) to be rendered by an 
OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing services from April 16, 2020 through April 
18, 2020. 
 
You asked the Plan to pay for skilled nursing services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the member elected hospice on April 16, 2020. During this time 
period, skilled nursing services when necessary would be covered under hospice, not Medicare Part C benefit. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for skilled nursing services from April 16, 2020 through April 
18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 2 pontics (D6240) and 5 retainer crowns (D6752). 
 
You asked the Plan to pre-approve the dental services. You say that you are having difficulty eating. The Plan 
denied your request. The Plan says the requested 7-unit fixed bridge replacing 2 upper front teeth is beyond the 
scope of the policy benefit 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. The Plan covers the dental 
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 dental services. Our reviewer says 
that the requested services do not meet the Plan's criteria for coverage. Our physician reviewer found there are 
2 anterior teeth that would need to be replaced. The reviewer found there is no noted physical or neurological 
condition that would preclude the use of a removable appliance. The reviewer also found that given the plan 
limitations, the requested optional treatment plan would not meet plan criteria for fixed bridgework. 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 2 pontics (D6240) and 5 retainer crowns (D6752).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar facet injection. 
 
You asked the Plan to pre-approve the requested services. You say that the blocks provided the enrollee enough 
relief to move forward with radiofrequency ablation. The Plan denied your request. The Plan says the enrollee's 
pain was not reduced by at least 80% after the last 2 injections. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical indications. 
 
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 requested services. Our physician 
reviewer found that the enrollee has back pain due to lumbar spondylosis without myelopathy or radiculopathy.  
The documents show that the current pain is rated 6 out of 10.  His pain can go up to an 8 out of 10. 
 
 
He has difficulty with any activity at home that involves standing for any length of time. He also has difficulty 
walking for any length of time, and standing up fully straight. He does get relief when he initially sits down. 
There has been ongoing physical therapy, supervised home exercises or chiropractic care since previous 
injection. Two therapeutic facet injections have been done in the past 12 months. After the last facet injection, 
the 50% reduction of pain lasted for at least 2 months. Right L4/L5 and L5/S1 medial branch blocks (MBB's) 
were done with 66-75% pain relief. According to the coverage criteria, only when dual MBBs provide greater 
than 80% relief of the primary or index pain and duration of relief is consistent with the agent employed may 
facet joint denervation with RF medial branch neurotomy be considered. Therefore, the requested injection is 
not medically reasonable to treat the enrollee. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a lumbar facet injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing provided on November 22, 2019. 
 
You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The documentation shows that testing for Carbamazepine (80157), Levetiracetam (80177), Topiramate 
(80201), Digoxin (80162), Clozapine (80159), and Haloperidol (80173) was provided. We find that the testing 
is not supported in the medical record. Specifically, the documentation does not show that a blood sample was 
provided of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
drug testing provided on November 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial nursing facility care (99306) provided on 
December 9, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for nursing facility care. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the initial nursing facility care (99306) provided 
on December 9, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 12, 2020 by an OON 
provider. 
 
You asked the Plan to pay for the unna boot strapping and wound care. You say that the enrollee required the 
services provided. The Plan denied your request. The Plan says the services were rendered by a non-contracted 
provider. The Plan also says that prior authorization was not obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on May 12, 2020 by 
an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve these services. You say that you need the item to go to doctor's 
appointments and to go out. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.