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

 
We decided that the Plan does not have to pre-approve the core buildup and crown for tooth #2 and a lower 
partial denture. 
 
You asked the Plan to pre-approve the core buildup and crown for tooth #2 and a lower partial denture. You 
say that you were diagnosed with gum disease and need to go to a periodontist as soon as possible. You say 
that you cannot afford this by yourself. The Plan denied your request. The Plan says the core buildup and 
crown are not medically necessary and you have exceeded the frequency limit for dentures. 
 
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 core 
buildup and crown for tooth #2 when the services are medically necessary and reasonable. The lower partial 
denture is only covered once every 5 years. The Plan paid for a lower partial denture provided on December 8, 
2016, which exhausted your benefit. 
 
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 core buildup and crown for tooth #2 
and a lower partial denture. Our reviewer says that the criteria for coverage has not been met. Our physician 
reviewer found that there does not appear to be a significant coronal breakdown to meet the criteria for 
coverage for a core buildup and crown restoration for tooth #2. 
 
  
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 core buildup and crown for tooth #2 and a lower partial denture have not 
been met. Therefore, we decided that the Plan does not have to pre-approve the core buildup and crown for 
tooth #2 and a lower partial denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an external CPAP machine battery. 
 
You asked the Plan to pre-approve the external battery. You say that you live in a rural area where electric 
power often fails. You say that, when this happens, it takes more than a week for the power systems to 
normalize. You say that without the requested battery your life is at risk because you cannot use your machine 
and you lose oxygen. The Plan denied your request. The Plan says the item in dispute is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The 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 item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. In addition, the 
item at issue in this appeal is considered to duplicate the function of your device's current electrical connection.  
Therefore, we decided that the Plan does not have to pre-approve an external CPAP machine battery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a white glass with metal crown on tooth #7, 8, 9, 10. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this service is limited to one per every sixty months. 
 
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 crowns once 
every five years.  
 
Crowns were received on tooth #7 and #8 on 12/4/15 and #9 and #10 on 9/22/16. This is less than five years 
ago.  Based on this information, we decided that the Plan's rules for coverage of the services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a white glass with metal crown on tooth #7, 
8, 9, 10.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right sacroiliac joint 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 clinical assessment does not implicate the facet joint as putative source of pain. 
 
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this case, the enrollee's back pain is associated with radicular symptoms to the hip and thigh. Straight 
leg raise test was positive at the 7/2020 and 6/2020 physical exams. In addition, a small area of avascular 
necrosis is also present and could be a source of pain. The review has determined that there has been at least 
three months of moderate to severe pain that hasn't responded to conservative care. The pain is associated with 
radiculopathy. There is no documentation provided indicating that the facet joint the main source of pain. The 
requested sacroiliac joint injection is not medically necessary or reasonable. 
 
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 a right sacroiliac joint injection for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips 
 
You asked the Plan to pre-approve the trips. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has used all of the one-way trips for the year. 
 
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 one-way 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a pre-operative physical exam for a knee replacement surgery. 
 
You asked the Plan to pre-approve the exam. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there are no diagnosis codes, procedure codes, or clinical documentation to support 
medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the exam. Our reviewer says that the 
requested exam is considered medically reasonable and necessary in this case. Our physician reviewer found 
the enrollee is indicated for a left total knee replacement. A pre-operative physical exam is supported by 
evidence based medical literature to determine his risk factors for surgery and optimize any potential 
comorbidity. This request is additionally supported by his age, the magnitude of the planned surgical 
procedure, and the associated risks of anesthesia. Therefore, this request for pre-operative physical exam for 
knee replacement surgery 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 the exam have been met. Therefore, we decided that the Plan has to pre-approve 
a pre-operative physical exam for a knee replacement surgery.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve CYP2C19, CYP2D6, CYP2C9, and UGT1A1 genetic 
testing. 
 
You asked the Plan to pre-approve genetic tests. You say that this testing is medically necessary. The Plan 
denied your request. The Plan says the denial of authorization for these tests is correct. 
 
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 genetic tests. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the requested tests are not considered medically necessary for the management of recurrent 
urinary tract infections and overactive bladder. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic tests have not been met. Therefore, we decided that the Plan does not 
have to pre-approve CYP2C19, CYP2D6, CYP2C9, and UGT1A1 genetic testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental bridge for teeth #4-6. 
 
You asked the Plan to pre-approve a bridge. The Plan denied your request. The Plan says this is 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 a bridge 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 a bridge. Our reviewer says that the 
requested bridge for teeth #4-6 is not medically reasonable and necessary. Our physician reviewer found that 
there is no evidence of any physical or neurological condition of any kind in the records provided, and 
therefore nothing that would preclude the placement of a removable prosthesis to replace the missing tooth #5. 
Although the bridge is a viable alternative treatment, the Plan provisions do not provide coverage for a fixed 
appliance in most circumstances. Given the documentation provided, the plan criteria for a fixed appliance has 
not been met. 
 
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 a bridge have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a dental bridge for teeth #4-6.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy duty hospital bed (E0303). 
 
You asked the Plan to pre-approve the hospital bed. You say that you would like reconsideration because based 
on the member's history, this hospital bed is indicated and recommended. The Plan denied your request. The 
Plan says the member's weight does not meet the criteria for this bed. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty extra wide hospital bed is covered 
if the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the hospital bed have not been met. Specifically, the record does not show that the member is 
between 350 and 600lbs. Therefore, we decided that the Plan does not have to pre-approve a heavy duty 
hospital bed (E0303).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the maxillofacial prosthesis (D5999). 
 
You asked the Plan to pre-approve the maxillofacial prosthesis (D5999). You say that a mandibular 
advancement device is medically necessary for treatment of moderate obstructive sleep apnea. 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 Plans 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 
maxillofacial prosthesis (D5999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dermatology services to be provided by an out of 
network provider. 
 
You asked the Plan to pre-approve the dermatology services with an out of network provider. You say that your 
dermatologist will not do an in-office full body scan right now. The Plan denied your request. The Plan says 
these services are available in network. 
 
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 
dermatology services to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery-powered nebulizer (E0570).
You asked the Plan to pre-approve a battery-powered nebulizer. You say that you need this as a backup for if
the power goes out. The Plan denied your request. The Plan says this is considered duplicative of the nebulizer
that was previously provided.
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 electric nebulizer. An electric nebulizer serves the same purpose as a batterypowered
nebulizer. Therefore, we decided that the Plan does not have to pre-approve a battery-powered
nebulizer (E0570).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height 
adjustments), with any type side rails, with mattress (CPT Code E0265). 
 
You asked the Plan to pre-approve the total electric bed. You say that the durable medical equipment (DME) is 
medically necessary. The Plan denied your request. The Plan says this item is not covered under Medicare or 
the Health Plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the total electric bed have not been met. The rules say that a total 
electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a 
convenience feature. Total electric beds will be denied as not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pre-approve hospital bed, total electric (head, foot and height adjustments), with 
any type side rails, with mattress (CPT Code E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network dialysis center. 
 
You asked the Plan to pre-approve the referral. You say that you have been an established patient at this 
dialysis center. 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 an out-of-network dialysis center.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sensor for use with interstitial continuous glucose 
monitoring coded with A9276 and a receiver (monitor); external, for use with interstitial continuous glucose 
monitoring system coded with A9278 for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The 
Plan denied your request. The Plan says that you did not submit the clinical information needed to approve 
coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that CGM devices covered by Medicare under the 
DME benefit are defined as therapeutic CGMs and that code A9276 is used to describe the supplies used with a 
non-therapeutic CGM. The rules also say that code A9278 describes any CGM system that fails to meet the 
DME Benefit requirements. 
 
We looked at the file and Medicare rules. Based on this information, we decided that you are requesting a non-
therapeutic CGM and supplies for a non-therapeutic CGM. Medicare will only cover therapeutic continuous 
glucose monitors and supplies. Therefore, we decided that the Plan does not have to pre-approve a sensor for 
use with interstitial continuous glucose monitoring coded with A9276 and a receiver (monitor); external, for 
use with interstitial continuous glucose monitoring system coded with A9278 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve physician services. You say that you had to go to this provider because of 
Covid-19. The Plan denied your request. The Plan says there are providers who are in-network that can provide 
these services going forward. 
 
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 
physician services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a podiatry office visit to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve a podiatry office visit. You say that you did not have a good experience with 
the in-network provider. You say that this is why you would like to see an out-of-network provider. The Plan 
denied your request. The Plan says there are in-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 podiatry office visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant placement (D6010), prefabricated abutment 
(D6056) and radiographic/surgical implant index (D6190). 
 
You asked the Plan to pre-approve implant placement (D6010), prefabricated abutment (D6056) and 
radiographic/surgical implant index (D6190). You say that you are no longer able to glue dentures in and are 
having trouble eating and speaking so you need implants. The Plan denied your request. The Plan says the 
services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
implant placement (D6010), prefabricated abutment (D6056) and radiographic/surgical implant index (D6190).