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

 
We decided that the Plan does not have to pre-approve the complete upper denture (D5110). 
 
You asked the Plan to pre-approve the complete upper denture (D5110). You say that the dentures are the 
incorrect size causing a choking hazard and you can't chew. The Plan denied your request. The Plan says a 
complete upper denture is only covered once every 8 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, you also have a maximum benefit of 
one complete upper denture every 8 years. The Plan paid for a complete upper denture provided on March 29, 
2016, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the 
complete upper denture (D5110).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high energy extracorporeal shock wave therapy (28890). 
 
You asked the Plan to pre-approve high energy extracorporeal shock wave therapy. You say that please see 
attached clinical to support the need for shockwave therapy. The Plan denied your request. The Plan says this 
procedure is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of high energy extracorporeal shock wave therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve high energy extracorporeal shock wave therapy (28890).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve BRCA 1 and BRCA 2 testing. 
 
You asked the Plan to pre-approve BRCA 1 and BRCA 2 testing. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
testing. 
 
The Plan must follow Medicare rules. Medicare rules say that BRCA 1 and BRCA 2 testing are only covered 
for certain indications. 
 
We looked at the file and Medicare rules. Review of the file does not support that you have a personal history 
of breast, pancreatic, or certain prostate cancers. Based on this information, we decided that Medicare rules for 
coverage of BRCA 1 and BRCA 2 testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve BRCA 1 and BRCA 2 testing.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve routine transportation. You say that you still have appointments to get to but 
do not have a way to get back and forth from these appointments. The Plan denied your request. The Plan says 
the denial of authorization for additional routine transportation is correct, because routine transportation 
beyond 12 one-way trips per year is not covered by the Plan. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 12 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624) to treat 
knee pain. 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that it is your medical 
opinion that the enrollee's left knee genicular radiofrequency ablation procedure denial be overturned. The 
enrollee would see significant benefits from this procedure. The Plan denied your request. The Plan says this 
procedure is still being studied in clinical trials for efficacy in the treatment of knee pain from osteoarthritis. 
 
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. Based on this information, we decided that Medicare rules for 
coverage of genicular nerve radiofrequency ablation have not been met. Therefore, we decided that the Plan 
does not have to pre-approve genicular nerve radiofrequency ablation (64624) to treat knee pain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (E1399). 
 
You asked the Plan to pre-approve the scooter. You say that the power scooter is medically necessary. The Plan 
denied your request. The Plan says there is no documentation that the enrollee can safely operate the PMD. 
 
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.  
 
The file does not include any documentation or assessment showing that the enrollee is capable of safely 
operating the provided scooter or that the enrollee's home is accessible to the requested scooter. This means 
that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you were diagnosed with COVID and had a heart 
attack know causing trouble with your mobility. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift 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 stair glide.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric connection between wheelchair controller 
and two or more power seating system motors identified with code E2311 and a USB charger identified with 
code K0108. 
 
 
 
You asked the Plan to pre-approve an electric connection between wheelchair controller and two or more 
power seating system motors and a USB charger. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that expandable controllers are only covered for 
certain indications. Medicare rules also say that for equipment to be covered, it must primarily serve a medical 
purpose.   
 
We looked at the file and Medicare rules. Review of the file shows that the approved power options come with 
their own switches and therefore, the requested expandable controller is not a covered benefit. The requested 
USB charger is considered a convenience item and does not service a medical purpose. Based on this 
information, we decided that Medicare rules for coverage of an electric connection between wheelchair 
controller and two or more power seating system motors and a USB charger have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an electric connection between wheelchair controller and 
two or more power seating system motors identified with code E2311 and a USB charger identified with code 
K0108.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the established patient office or other outpatient visit 
(99211, 99213, 99212) to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the established patient office or other outpatient visit. You say that the 
services requested are medically necessary. The Plan denied your request. The Plan says the requested provider 
is not participating within your health plan. 
 
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 established patient office or other outpatient visit (99211, 99213, 99212) 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 the patient office consultation (99242) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve the patient office consultation. You say that the provider you are requesting 
offers a comprehensive range of services. The Plan denied your request. The Plan says they have referred you 
to a network ophthalmologist who can provide the full range of ophthalmology services for your diagnosis. 
 
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 patient office consultation (99242) 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 power operated vehicle. 
 
You asked the Plan to pre-approve a power operated vehicle. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested 
item. 
 
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.  
 
The file does not support that you have a mobility deficit that impairs your participation in MRADLs, your 
condition cannot be improved by a walker, cane or manual wheelchair, or that you can safely operate the PMD 
being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power operated vehicle.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve kyphoplasty for a L2 Wedge compression fracture of 
second lumbar vertebrae. 
 
You asked the Plan to pre-approve kyphoplasty for a L2 Wedge compression fracture of second lumbar 
vertebrae. 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 medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that kyphoplasty is only covered for certain 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 kyphoplasty for a L2 Wedge 
compression fracture of second lumbar vertebrae. Our reviewer says that the documentation does not support 
that the requested services are medically reasonable or necessary. Our physician reviewer found the MRI does 
not show an acute fracture. In addition, recent literature shows kyphoplasty is not effective for compression 
fractures. Therefore, the enrollee does not meet criteria for the requested 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 kyphoplasty for a L2 Wedge compression fracture of second lumbar vertebrae 
have not been met. Therefore, we decided that the Plan does not have to pre-approve kyphoplasty for a L2 
Wedge compression fracture of second lumbar vertebrae.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ErecAid Classic vacuum erection system. 
 
You asked the Plan to pre-approve the ErecAid Classic vacuum erection system. You say that this would 
benefit the enrollee. The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that vacuum erection devices and related accessories 
are statutorily non-covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ErecAid Classic vacuum erection system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the ErecAid Classic vacuum erection system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extraction and two bone replacement grafts for ridge 
preservation. 
 
You asked the Plan to pre-approve the extraction and bone replacement grafts. You say that you have 
infections that you need taken care of because of health reasons. The Plan denied your request. The Plan says 
the maximum quarterly allowance has been met. 
 
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 offers a $500 quarterly 
allowance fro comprehensive dental services. The record shows that at the time these services were requested, 
the Plan had already approved coverage for two bone replacement grafts, two guided tissue regenerations, and 
partially approved an extraction, which added up to $1,500.00, exhausting the comprehensive dental allowance 
for the first three quarters. You can resubmit the claim for pre-approval under your fourth quarter allowance of 
$500. Therefore, we decided that the Plan does not have to pre-approve an extraction and two bone 
replacement grafts for ridge preservation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture (D5110) and lower partial 
denture (D5212). 
 
You asked the Plan to pre-approve the complete upper denture (D5110) and lower partial denture (D5212). 
You say that the enrollee has severe bone loss and the denture is not fitting properly. You say that the reline is 
making the fit worse. The Plan denied your request. The Plan says the service exceeds the maximum count 
allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan also has a maximum benefit 
of one complete upper denture and one lower partial denture every five plan years. The Plan paid for a 
complete upper denture on February 8, 2019 and a lower partial denture on November 3, 2017, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper 
denture (D5110) and lower partial denture (D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. 
 
You asked the Plan to pre-approve the compression stockings. You say that you require the stockings for 
venous insufficiency. The Plan denied your request. The Plan says compression gradient stocking is statutorily 
not a covered benefit based on Medicare coverage indications. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6531 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6531.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient laboratory services. 
 
You asked the Plan to waive the copayment for outpatient laboratory services. You say that you feel you 
shouldn't have to pay a copayment. The Plan denied your request. The Plan says the copayment has been 
correctly applied. 
 
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 $30 
copayment for outpatient diagnostic tests.  
 
You have been asked to pay a $30 copayment for outpatient laboratory services. The requested outpatient 
laboratory services fall within the outpatient diagnostic tests 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 outpatient laboratory services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom made orthotics, shoe inserts (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that the medical records provided support the 
necessity of the services in dispute. 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 custom made orthotics, shoe 
inserts (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the complete upper denture. 
 
You asked the Plan to pre-approve the complete upper denture. You say that you are appealing the denial. The 
Plan denied your request. The Plan says your denture benefit is exhausted. 
 
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, you also have a maximum benefit of 
one complete or partial denture every 60 months. The Plan paid for a complete upper denture provided on 
October 24, 2017, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-
approve the complete upper denture.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee arthroscopy with meniscectomy. 
 
You asked the Plan to pre-approve the knee surgery. You say that this procedure is needed to address the 
enrollee's pain. The Plan denied your request. The Plan says this is not appropriate in the setting of severe 
degenerative joint disease. 
 
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 knee surgery. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this enrollee presents with complaints of right knee pain and swelling. She reported an acute 
onset of symptoms in June/July 2020 when she tripped going up stairs and twisted her right knee. There is 
radiographic evidence of significant medial compartment arthritis and some patellofemoral narrowing. There is 
imaging evidence of moderately severe medial and mild lateral and patellofemoral compartment osteoarthritis, 
and a lateral meniscus tear. She had failed to achieve adequate improvement with activity modification, 
NSAIDs, and cortisone injection.  
 
Under consideration is a request for right knee arthroscopy and lateral meniscectomy. Current evidence based 
medical literature would not fully support surgery in this enrollee's significantly degenerative knee setting. 
There is evidence of significant osteoarthritis and no clear evidence that comprehensive conservative treatment 
had been attempted and failed. There are no significant positive meniscal signs documented to support an 
exception to guidelines. Therefore, this request for knee arthroscopy and meniscectomy would not be 
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 knee surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a knee arthroscopy with meniscectomy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 20 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you do not have any other way to get to your 
doctor appointments. You need approximately 10 more round trips so that you can get to all of your remaining 
appointments this year. The Plan denied your request. The Plan says this request exceeds the benefit frequency 
limitation. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 50 one way trips per year trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 20 additional routine transportation trips.