Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital bed and supplies provided on September 6, 2017, 
to September 15, 2017 by an out of network (OON) provider. 
 
You asked the Plan to pay for a hospital bed and supplies. You say that this equipment was provided in good 
faith. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your 
request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care 
physician did not refer these services. 
 
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 a hospital bed and supplies provided on September 
6, 2017, to September 15, 2017 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch nerve block injections. 
 
You asked the Plan to pre-approve paravertebral facet joint injections (64493, 64494, 64495). You say that the 
enrollee needs medial branch blocks for pain relief. The Plan denied your request. The Plan says there is 
positive radiculopathy and positive annular tear therefore the request cannot be approved. 
 
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 paravertebral facet joint injections 
(64493, 64494, 64495). Our reviewer says that the requested services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found there are several other probable pain generators that 
have not been addressed. Therefore, this does not meet the criteria for medial branch blocks as listed in the 
LCD. Therefore, the request is deemed not medically reasonable or 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 paravertebral facet joint injections (64493, 64494, 64495) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve medial branch nerve block injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7140) for teeth # 24, 25, and 26. 
 
You asked the Plan to pre-approve the extractions. The Plan denied your request. The Plan says that extractions 
are not listed as a covered service. 
 
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 
extractions (D7140) for teeth # 24, 25, and 26.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression 
(PILD) surgery. 
 
You asked the Plan to pre-approve PILD procedure. You say that the enrollee needs this procedure to reduce 
the pain and allow her to complete activities of daily living. The Plan denied your request. The Plan says the 
denial of authorization for this service is correct, because this procedure is only covered by Medicare in the 
context of an approved clinical study. 
 
The Plan must follow Medicare rules. Medicare rules say that PILD is only covered for beneficiaries who are 
enrolled in an approved clinical study.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of PILD procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve percutaneous image-guided lumbar decompression (PILD) surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lightweight manual wheelchair identified with code 
K0003. 
 
You asked the Plan to pre-approve a lightweight manual wheelchair. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that lightweight manual wheelchairs are 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 a lightweight manual wheelchair. Our 
reviewer says that the documentation does not support that the requested lightweight manual wheelchair is 
medically reasonable or necessary. Our physician reviewer found the documentation does support that you 
have a personal mobility deficit but does not reveal clearly that this deficit impairs participation in mobility 
related activities of daily living in the home. The documentation does not reveal why your mobility deficit is 
unable to be helped by a standard manual wheelchair. The documentation is not clear that you can safely 
maneuver the wheelchair in the home. 
 
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 lightweight manual wheelchair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a lightweight manual wheelchair identified with code K0003.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for teeth # 4, 20, 28, and 29. 
 
You asked the Plan to pre-approve the crowns. You say that your crowns have fallen off. You also say that 
there is a bad odor. The Plan denied your request. The Plan says the crowns for teeth # 4 and 20 are not 
medically necessary. The Plan says that crowns are covered once every 5 years. The Plan also says that the 
frequency limit for the crowns for teeth # 28 and 29 have 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. The Plan covers the crowns 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crowns. Our reviewer says that the 
crowns for teeth # 4 and 20 are not medically necessary. Our physician reviewer found that tooth # 4 has 
existing endodontic treatment and an existing post and crown restoration. The reviewer found that the provided 
x-ray shows that the tooth does not appear to be reasonably restorable. The reviewer found that a replacement 
crown, given the supplied information, would not be reasonably possible and not medically necessary. The 
reviewer found that tooth # 20 is also endodontically treated and has an existing post and crown. The reviewer 
also found that, given the supplied x-ray, there is no clear defect of the existing crown. Therefore, the reviewer 
found that the requested crowns for #4 and #20 are not medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crowns have not been met. Additionally, the record shows that the crowns 
for teeth # 28 and 29 were placed on May 23, 2017, less than 5 years ago. Thus exhausting the benefit for 
crowns on these teeth. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for 
teeth # 4, 20, 28, and 29.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you need LTACH services. The Plan 
denied your request. The Plan says clinical assessment does not support a LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be requiring additional short term acute care services to 
complete treatment and continue weaning which can be safely performed at the current facility. The enrollee 
does not require services at the LTACH that are not already available at the current facility.  There are no 
services at the LTACH that the enrollee requires that are not already available and covered at the current 
facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. 
Transfer may be considered when the enrollee is more stable. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0364) for 
tooth #18. 
 
You asked the Plan to pre-approve the dental service. You say that your tooth has been causing you pain. You 
say that you should be told what services are not covered when you sign up for the plan. You also say that you 
think there may be a root that was not full removed during a previous root canal. The Plan denied your request. 
The Plan says cone beam CT is not listed as a covered service. 
 
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 
cone beam CT capture and interpretation (D0364) for tooth #18.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs. 
 
You asked the Plan to pre-approve power wheelchair repairs. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says as the cost of the repairs have exceeded the 
cost of replacement, repairs cannot be approved at this time. Replacement is required. 
 
The Plan must follow Medicare rules. Medicare rules say that repairs can only be covered up to the estimated 
cost of replacement. 
 
We looked at the file and Medicare rules. In this case, total repairs the Plan has paid for including the current 
request is $32,673.44 for this power wheelchair. This is more than the estimated cost to replace this power 
wheelchair. As such, no further repairs are covered, though replacement is an option if requested. Based on this 
information, we decided that Medicare rules for coverage of power wheelchair repairs have not been met. 
Therefore, we decided that the Plan does not have to pre-approve power wheelchair repairs.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT angiography provided on April 23, 
2019. 
 
You asked the Plan to waive the copayment for the CT angiography. You say that it should not take that long 
for a bill to come. You say that you don't think this bill is fair. The Plan denied your request. The Plan says the 
copayment applied correctly. 
 
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 $350 
copayment for Medicare-covered outpatient diagnostic radiology services such as MRI's and CT scans. 
 
You have been asked to pay $216.06, which is less than the standard $350 copayment for the CT angiography. 
The CT angiography falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the CT angiography provided on April 23, 
2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature or bag hooks. 
 
You asked the Plan to pre-approve a power seat elevation feature (E2300) and bag hooks (K0108). You say 
that the enrollee needs a power wheelchair with a power seat elevation feature and bag hooks. The Plan denied 
your request. The Plan says a power seat elevation feature and bag hooks do not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
These items are not primarily medical in nature and are not covered by Medicare or the Plan. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation feature or bag hooks.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet injections (64493, 64494, 64495). 
 
You asked the Plan to pre-approve facet injections. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered under certain 
circumstances. 
 
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 facet injections. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found in this case, the enrollee has 
documented radiculopathy. The review has determined that the enrollee does not meet the coverage criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of facet injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facet injections (64493, 64494, 64495).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the re-treatment of a previous root canal (D3347) for 
tooth # 29. 
 
You asked the Plan to pre-approve the dental service. You say that needs to have root canal retreated in order to 
preserve her tooth and have the crown reattached. You say that this is the only chance to preserve the existing 
tooth. You say that if the tooth cannot be preserved your only other option is to have the tooth extracted and 
then you would need an implant which is not covered. You also say that living with a missing tooth, without an 
implant, is too painful to for you to function. The Plan denied your request. The Plan says re-treatment of a 
previous root canal is not listed as a covered service. 
 
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 
re-treatment of a previous root canal (D3347) for tooth # 29.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that you are unsteady on your feet. You say that 
your doctor at the hospital felt strongly that you needed extra help before going home. The Plan denied your 
request. The Plan says the records show that the enrollee's condition does not meet the requirements for 
coverage of SNF services. The Plan says that the enrollee's condition is stable, and she is scheduled for 
discharge. The Plan says that the records do not show that the enrollee requires daily skilled rehabilitation 
therapy or complex daily nursing care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee 
is ambulating more than 100 feet. Daily skilled services are not required to establish a maintenance program or 
to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as 
a practical matter, can be provided at a lower level of care. 
 
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 SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Neulasta. 
You asked the Plan to pre-approve Neulasta. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says that the requested drug is not medically necessary. 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
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 Neulasta. Our reviewer says that the 
documentation does support that the requested drug is medically reasonable and necessary. Our physician 
reviewer found the enrollee will receive post-induction high dose Cytarabine to treat acute myelogenous 
leukemia. The NCCN Guidelines Version 2.2021 Acute Myeloid Leukemia (Age over 18 years) page AL-E 
states growth factors may be considered as a part of supportive care for post-remission therapy. Neulasta is a 
growth factor. The enrollee had neutropenic fever during the enrollee's hospital stay for induction 
chemotherapy. The use is not listed as not indicated, not recommended or not supported in any of the 
compendia. Therefore, the documentation supports that the use of Neulasta is medically reasonable and 
necessary and safe and effective for the enrollee. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have been met. Therefore, we decided that the Plan has to pre-approve Neulasta.
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 went to get dentures on May 18, 2017. You say that the dental provider has not been able to make dentures that fit you properly. You say that your dentist finally told you that he cannot make her dentures. You say that you do not have dentures right now. You say that you need them to eat as you only have 8 teeth total. The Plan denied your request. The Plan says partial 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, the frequency limit for partial dentures has been reached. The record shows that the Plan paid for partial dentures that you received on May 18, 2017, thus exhausting the benefit. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested device is not medically necessary. 
 
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 a power wheelchair. Our reviewer says 
that the documentation does not support that the requested power wheelchair is medically reasonable or 
necessary. Our physician reviewer found the documentation does support that you have a personal mobility 
deficit but it is not clear that this deficit impairs participation in mobility related activities of daily living in the 
home. The documentation does not reveal why your mobility deficit is unable to be helped by a walker, cane, 
or manual wheelchair. There is no objective gait or detailed neuromuscular exam. The documentation is not 
clear that you can safely maneuver the power operated vehicle in the home or that the requested wheelchair 
will significantly improve activities of daily living performance in the home. Therefore, you do not meet 
criteria for the requested item. 
 
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 power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.