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

 
We decided that the Plan does not have to pre-approve an epidural injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested injection is not supported as part of a series. 
 
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 injection. Our reviewer says that the 
requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this case, there is no record of herpes zoster or of radicular pain corresponding to the distribution of a 
specific dermatome. There is no record of neurogenic claudication. The review has determined that the enrollee 
does not meet the criteria for this request. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve botox injections (J0585). 
 
You asked the Plan to pre-approve the botox injections. You say that the injections are medically necessary. 
The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that botox injections are covered when 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 botox injections. Our reviewer says 
that the injections are not medically necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the requested Botox injections are medically necessary. Bilateral hip 
bursitis and psoas syndrome are not among the Medicare approved indications for Botox injections. 
 
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 botox injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve botox injections (J0585).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day Reader. 
 
You asked the Plan to pre-approve the Freestyle Libre. You say that you would like reconsideration because 
the member needs to test four times daily and has issues with testing. The Plan denied your request. The Plan 
says the record does not show that the member is checking their blood sugar three times a day or that they are 
on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies are 
covered by Medicare when the beneficiary has been using a BGM and performing frequent (four or more times 
a day) testing and when the beneficiary is insulin-treated with multiple (three or more) daily injections of 
insulin or a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Freestyle Libre have not been met. Specifically, the records do not show that the member is 
testing they blood glucose four or more times a day or that they are insulin treated with multiple injections of 
insulin or a Medicare-covered continuous subcutaneous insulin infusion pump. Therefore, we decided that the 
Plan does not have to pre-approve a Freestyle Libre 14 Day Reader.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that the enrollee is wheelchair bound but unable to 
manually turn wheels. The Plan denied your request. The Plan says a DME consulting evaluation reported that 
the enrollee can independently self-propel and access all areas of the home. 
 
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.  
 
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 wheelchair is not medically reasonable or necessary. Our physician reviewer found the 
documentation does not reveal that the enrollee's personal mobility deficit impairs participation in MRADLs in 
the home. The enrollee's personal mobility is currently helped by a manual wheelchair. The documentation 
reveals possible dementia; therefore, it is not clear that the enrollee would be able to safely maneuver the power 
wheelchair. 
 
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 wheelchair for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill. 
 
You asked the Plan to pre-approve special supplemental benefits for the chronically ill. You say that you were 
told by the seller that you qualified for the Plan's pay card. The representatives offer benefits that they do not 
give members. The Plan denied your request. The Plan says the enrollee does not meet the criteria listed in the 
Evidence of Coverage to receive the special supplemental benefits for the chronically ill. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  However, the Plan offers a special supplemental benefit that exceeds Medicare 
coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the plan offers a benefit in excess of Medicare coverage, we decided that Medicare rules for coverage 
of the special supplemental benefits for the chronically ill have not been met. Therefore, we decided that the 
Plan does not have to pre-approve special supplemental benefits for the chronically ill.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010), prefabricated abutment (D6056), and abutment supported porcelain/ceramic crown (D6058). 
 
You asked the Plan to pre-approve the endosteal implant, prefabricated abutment, and abutment supported 
porcelain/ceramic crown. You say that an implant to replace your missing tooth is advised to prevent further 
damage. You also say that you cannot afford to pay for these services. The Plan denied your request. The Plan 
says these services are not covered under your benefit package. 
 
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 a 
surgical placement of implant body: endosteal implant (D6010), prefabricated abutment (D6056), and abutment 
supported porcelain/ceramic crown (D6058).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan. Our reviewer says that the 
documentation does not support that the requested CT scan is medically reasonable or necessary. Our physician 
reviewer found the enrollee is reported to have epigastric pain and weight loss. A detailed history of these 
issues, including the amount and duration of the weight loss, is not documented. There is no evidence that the 
enrollee has received a CXR or been referred to a gastroenterologist.  While ongoing evaluation is reasonable, 
multiple CT scans, as a method of diagnostic screening are not medically necessary or reasonable. 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 a CT scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a CT scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facial/nose reconstructive surgery to be provided by an 
out of network (OON) provider. 
 
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services can be provided by a 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 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 
facial/nose reconstructive surgery to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan. 
 
You asked the Plan to pre-approve a CT scan. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a CT scan. Our reviewer says that the 
documentation does support that the requested CT scan is medically reasonable and necessary. Our physician 
reviewer found the enrollee has a history of left lower quadrant pain, history of diverticulosis, and has prior 
inflammatory lesion on an old CT scan of abdomen. The documentation supports that there are several 
indications for the requested scan. Diverticulitis is in the differential of this specialist. The enrollee also has an 
old lesion that needs to be better characterized. Therefore, the requested CT scan is 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 a CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a full mouth debridement (D4355). 
 
You asked the Plan to pre-approve the full mouth debridement. You say that your teeth are sensitive, and you 
need these procedures. The Plan denied your request. The Plan says this 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, full mouth debridement (D4355) is 
limited to one procedure every three plan years. The record shows that you received a full mouth debridement 
(D4355) on January 31, 2019, and your full mouth debridement (D4355) benefit has been exhausted. 
Therefore, we decided that the Plan does not have to pre-approve a full mouth debridement (D4355).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve Injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral. 
 
You asked the Plan to pre-approve lumbar sacral facet injections, (64493, 64494, 64495). You say that the 
enrollee has failed extensive conservative treatment. The Plan denied your request. The Plan says that the 
records do not show the enrollee has the type of pain that supports this procedure. 
 
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 lumbar sacral facet injections, (64493, 
64494, 64495). Our reviewer says that the requested services are considered medically reasonable and 
necessary in this case. Our physician reviewer found this enrollee has axial back pain.  The enrollee has had 
extensive conservative therapy. The physical exam supports facet joint dysfunction. The requested procedure 
meets the LCD criteria and is 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 lumbar sacral facet injections, (64493, 64494, 64495) have been met. Therefore, 
we decided that the Plan has to pre-approve Injection(s), diagnostic or therapeutic agent, paravertebral facet 
(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or 
sacral.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prostate biopsy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records show that you 
have an elevated prostate specific antigen (PSA) of 5.7 ng/mL. There were no palpable nodules on exam, and 
you have not had a prior biopsy performed. The submitted records do not support that the requested saturation 
biopsy is reasonable or medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a prostate biopsy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three osseous surgeries (D4261 x3) and three bone 
replacement grafts (D4263 x3). 
 
You asked the Plan to pre-approve the osseous surgeries and bone replacement grafts. You say that your 
benefit guide says that you have a dental benefit limit of $2,000 for all covered dental services. The Plan denied 
your request. The Plan says these services are not covered under your 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 three 
osseous surgeries (D4261 x3) and three bone replacement grafts (D4263 x3).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on January 31, 
2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 medical services provided to the enrollee on January 31, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the brain. 
 
You asked the Plan to pre-approve MRI. You say that you are appealing with records. The Plan denied your 
request. The Plan says that the denial of authorization for this test is correct, because the enrollee's physical 
examination was normal and there are no records of a visit with an ear, nose, throat (ENT) specialist. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that the 
enrollee meets the Medicare criteria for the requested MRI. Our physician reviewer found schwannoma is very 
difficult to detect and could be the cause of the enrollee's symptoms. An MRI is 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
Magnetic Resonance Imaging (MRI) of the brain.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on March 16, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for practitioner visit. You say that your provider depends upon the facility staff to 
verify eligibility and obtain authorization. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because this provider is out-of-network with the Plan and 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 March 16, 2020 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6241) for tooth #'s 23, 24, & 25 and retainer 
crowns (D6751) for tooth #'s 22, 23, & 27. 
 
You asked the Plan to pre-approve the pontics and retainer crowns. You say that you feel these services are 
medically necessary. The Plan denied your request. The Plan says these services are not medically necessary. 
 
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 pontics 
and retainer 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 pontics and retainer crowns. Our 
reviewer says that the coverage criteria has not been met. Our physician reviewer found there has been no 
showing of a physical or neurological problem that would preclude the use of a removable appliance.  The Plan 
also limits the use of a bridge to two lower anterior teeth, and in this case, there would be three teeth being 
replaced.  Our reviewer found that clinically, the chosen abutment of tooth #22 is unreliable in the long term 
due to periodontal disease that has caused loss of bone support on the mesial aspect, and the bridge requested 
appears to extend to tooth #27, though not mentioning tooth #26, which is still present.  At a purely clinical 
level, the requested bridge would be questionable due to the periodontal issues. Our physician reviewer also 
found that, given the provided records, the criteria for a fixed bridge has not been met and there is no necessity 
for the requested treatment. 
 
 
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 pontics and retainer crowns have not been met. Therefore, we decided that 
the Plan does not have to pre-approve pontics (D6241) for tooth #'s 23, 24, & 25 and retainer crowns (D6751) 
for tooth #'s 22, 23, & 27.