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

 
We decided that the Plan does not have to pre-approve the bone replacement graft. 
 
You asked the Plan to pre-approve the bone replacement graft. You say that you are going to have trouble 
chewing causing your jaw to hurt. You say that you need an extraction but insurance wants a bridge instead of 
a permanent tooth. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
bone replacement graft.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you have multiple health issues causing 
incontinence. 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 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 incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from 
February 26, 2020 to May 14, 2020. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received Medicare Part B drugs on February 26, 2020. The total allowed amount is $3,161.28 and 20% of 
that is $632.25. 
 
You received Medicare Part B drugs on May 14, 2020. The total allowed amount is $3,195.36 and 20% of that 
is $639.07. 
 
The total amount you owe is: $1,271.32. 
 
You have been asked to pay the total coinsurance amount of $1,271.32 for Medicare Part B drugs. Medicare 
Part B drugs fall within the Medicare Part B prescription drugs 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 coinsurance for Medicare Part B drugs provided from February 26, 2020 to May 14, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. 
The Plan denied your request. The Plan says this is not supported for the enrollee's condition. 
 
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 insertion of a Vertiflex device. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the Vertiflex 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 the insertion of a Vertiflex device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
17, 2020. 
 
You asked the Plan to pay for the dental service. You say that this was your only dentist appointment this year. 
The Plan denied your request. The Plan says comprehensive oral evaluations are covered once every 3 years. 
You say that the frequency limit for this service has been exceeded. 
 
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 the comprehensive oral evaluation 
is a covered service, the frequency limit of once every 3 years has been exceeded. The record shows that the 
Plan paid for a comprehensive oral evaluation that you received on July 10, 2019. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 
must receive care from a network provider and in most cases, care received from an out-of-network provider (a 
provider who is not part of our plan?s network) will not be covered, except for the following: emergency care 
or urgently needed service and needed medical care that Medicare requires our plan to cover and the providers 
in our network cannot provide this care (authorization is required). 
 
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 services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental items. You say that the dentures you have are crooked. You say 
that you have made multiple attempts to get them fixed. You say that you are still having issues with them as 
there is about 1 inch between them. You say that the dentist came in with a smart attitude and glued them in 
and left. The Plan denied your request. The Plan says complete dentures are covered once every 5 plan years. 
The Plan also 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 dentures are a covered service, the 
frequency limit of once every 5 plan years has been reached. The record shows that the Plan previously paid for 
a complete set of dentures that you received on October 31, 2018. Therefore, we decided that the Plan does not 
have to pre-approve a complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for specialist services provided on March 18, 
2020 and April 10, 2020. 
 
You asked the Plan to waive the copayments for specialist services. You say that your secondary insurance 
should cover the charges. The Plan denied your request. The Plan says the claims were processed correctly and 
you are being charged the correct amount. 
 
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 $50 
copayment for each specialist visit.  
 
You have been asked to pay the total allowed amount of $68.40, which is less than the total copayment amount 
for specialist services. Specialist services fall within the physician/practitioner services, including doctors 
office visits 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 copayments for specialist services 
provided on March 18, 2020 and April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 4, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
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 did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve shoe lifts. 
 
You asked the Plan to pre-approve these services. You say that the enrollee has a lower limb deformity. The 
Plan denied your request. The Plan says the services are not covered. 
 
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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve shoe 
lifts.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Odansetron, 4 mg tablet. 
 
You asked the Plan to pre-approve Odansetron. You say that the enrollee needs this drug to help combat nausea 
related to chemotherapy. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan says the requested drug is not covered under 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 Odansetron, 4 mg tablet.  
 
Benefits for Odansetron 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT). 
 
You asked the Plan to pre-approve image-guided radiation therapy. The Plan denied your request. The Plan 
says this is not medically necessary. 
 
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 image-guided radiation therapy. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that in this case, the intent of IGRT is clearly palliative, and it is not clear what 
benefit IGRT would afford. There is no justification for the need for IGRT that is provided in the case file. It 
seems as though IGRT is simply being used as routine practice, as there does not seem to be any exceptional 
circumstances with this enrollee necessitating the need for IGRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of image-guided radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve image-guided radiation therapy (IGRT).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cologuard coloerectal cancer screening. 
 
You asked the Plan to pre-approve the screening. You say that this is medically necessary. The Plan denied 
your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered for people 50-85 
years old. 
 
You are 88 years old. Based on this information, we decided that Medicare rules for coverage of the screening 
have not been met. Therefore, we decided that the Plan does not have to pre-approve Cologuard coloerectal 
cancer screening.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental items. You say that you only have 2 teeth. You also say that you 
are losing your other teeth. The Plan denied your request. The Plan says partial dentures are covered once every 
5 years. The Plan says 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 partial dentures are a covered 
service, the frequency limit of once every 5 years has been reached. The record shows that the Plan previously 
paid for partial dentures that you received on August 23, 2017. Therefore, we decided that the Plan does not 
have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 30, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 30, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on May 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on March 19, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on March 19, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on March 
19, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 6, 2020. 
 
You asked the Plan to pay for ambulance services. You say that the enrollee was bed confined and unable to sit 
in a wheelchair van. You say that no other service was willing to take the enrollee home. The Plan denied your 
request. The Plan says Original Medicare is responsible for payment. 
 
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 ambulance services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator. 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that you need a different oxygen 
concentrator because the long hose is a fall risk. The Plan denied your request. The Plan says the requested 
item is a duplicate. 
 
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 an oxygen concentrator. an oxygen concentrator serves the same purpose as an 
oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
service is available within the network and your condition is not 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance transportation provided on May 23, 2020. 
 
You asked the Plan to pay for the transportation. The Plan denied your request. The Plan says that this is not 
covered. 
 
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 indicates that the HN modifier does not indicate hospital to nursing 
facility. While this may be true, the Plan has not provided documentation or rationale as to why the HN 
modifier should not be used in this case, and ambulance transfer from a hospital facility to a SNF is covered by 
Medicare. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided 
that the Plan has to pay for the ambulance transportation provided on May 23, 2020.  
 
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 pay for a mattress to be provided. 
 
You asked the Plan to pay for a mattress. You say that the specific mattress you need is not available from in-
network providers. The Plan denied your request. The Plan says items from suppliers that are not enrolled in 
Medicare are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for 
services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare 
program. 
 
We looked at the file and Medicare rules. The requested supplier is not enrolled in the Medicare program. 
Based on this information, we decided that Medicare rules for coverage of a mattress have not been met. 
Therefore, we decided that the Plan does not have to pay for a mattress to be provided.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Durolane. Our reviewer says that the 
enrollee has not met the step therapy requirements for coverage of the requested drug. Our physician reviewer 
found that the enrollee has not previously trialed viscosupplemental treatment such as Orthovisc and Monovisc. 
Step therapy, as outlined by the plan, requires that these be trialed first. The documentation does not outline 
contraindications or reasons these medications were not considered. Without the support of the documentation, 
Durolane is not approved, as step criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.