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

 
We decided that the Plan does not have to pre-approve eyeglasses for the enrollee. 
 
You asked the Plan to pre-approve eyeglasses. You say that the enrollee had brain surgery and needs new 
glasses. The Plan denied your request. The Plan says that you are not eligible for new glasses. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers eyewear every two years. 
 
We looked at the file and the Plan's rules. The file indicates the Plan covered glasses for the enrollee on January 
3, 2019, which is less than 2 years ago. Based on this information, we decided that the Plan's rules for coverage 
 
 
of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pre-approve eyeglasses 
for the enrollee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen w/dye (74160) 
and a computed tomography (CT) scan of the thorax w/ dye (71260). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that the requested services are 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 these services. Our reviewer says that a 
CT scan of the abdomen and thorax are medically necessary. Our physician reviewer found that it has been 
over twelve months since the last CT scan. Therefore, a CT scan is medically indicated 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the abdomen w/dye (74160) and a computed tomography (CT) 
scan of the thorax w/ dye (71260).  
 
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 pay for the drug testing rendered on April 13, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing 
rendered on April 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor. 
 
You asked the Plan to pre-approve Dexcom G6. You say that the enrollee needs a continuous glucose monitor. 
The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the 
enrollee has not tried and failed the Plan's preferred CGM system and the prescriber has not sent a statement 
explaining why the enrollee cannot use the preferred system. 
 
The Plan must follow Medicare rules. Medicare rules say that a Plan may specify brands and manufacturers as 
preferred and may limit equipment to only those preferred brands/manufacturers as long as the enrollee retains 
access to all medically necessary items.  
 
We looked at the file and Medicare rules. The requested continuous glucose monitor is not the Plan's preferred 
brand. The record does not show that the enrollee cannot use the Plan's preferred brand of Freestyle, or that it 
is necessary for the enrollee to use the specific Dexcom G6 CGM system. Based on this information, we 
decided that Medicare rules for coverage of Dexcom G6 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation and lumbar facet injections. 
 
You asked the Plan to pre-approve lumbar facet injections (64493). You say that you would like to perform all 
procedures at the same time. The Plan denied your request. The Plan says radiofrequency ablation is approved 
and lumbar facet injections should not be done on the same date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. It is not routinely necessary to perform the procedures on the same 
day. Based on this information, we decided that Medicare rules for coverage of lumbar facet injections (64493) 
have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation 
and lumbar facet injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean oral exam (D0120).You asked the Plan to pre-approvethe dental service. You say that your pre-treatment estimate was denied due to the provider not submitting the billing NPI number.The Plan denied your request. The Plan says 2 oral exams per calendar year are covered. The Plan also says that the frequency limit has been reached.Medicaregenerally 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, thefrequency limit of 2 per calendar year has been reached. The record shows that the Plan paid for oral exams that you received on January 16, 2020 and January 23, 2020.Therefore, we decided that the Plan does not have to pre-approvean oral exam (D0120).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
10, 2020 to April 13, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the code 
G0299 (Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting) has a 
status indicator equal to "X" on the physician fee schedule, which is not in the statutory definition of physician 
services for fee schedule payment purposes. The billed charges are Home Health Skilled Nursing services and 
must be reported on HH PPS claims with the corresponding revenue code. Therefore, we decided that the Plan 
does not have to pay for the home health services provided to the enrollee from April 10, 2020 to April 13, 
2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Praluent pen. 
 
You asked the Plan to pre-approve Praluent pen. You say that you want the enrollee treated with this drug. The 
Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit. 
 
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 Praluent pen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 2. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee needs a crown for tooth # 2. 
The Plan denied your request. The Plan says documentation provided demonstrates sub-crestal decay. The Plan 
also says that the tooth has a poor long-term prognosis. 
 
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 dental 
service 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 dental service. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the provided documentation shows 
that in this instance there is only the involved ML surface. Given the presentation of this case with the supplied 
documentation, the reviewer found that the criteria for crowns on the #2 molar tooth is not met and there is no 
necessity for the requested procedure. 
 
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 dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2751) for tooth # 2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you need this to get around. The Plan denied 
your request. The Plan says that you have upper extremity function to self-propel a manual wheelchair in 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 patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4261) for 2 quadrants, and bone 
replacement grafts (D4263) for teeth # 3 and 14. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has bone loss in the upper left 
and upper right quadrants. The Plan denied your request. The Plan says osseous surgery is not listed as a 
covered service. The Plan says bone replacement graft is not listed as a covered service. The Plan also says any 
services not listed are not covered. 
 
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 
osseous surgery (D4261) for 2 quadrants, and bone replacement grafts (D4263) for teeth # 3 and 14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve2 alveoloplasty and 9 extractions for erupted teeth.You asked the Plan to pre-approvethe dental services. You say that you had surgery to fix a sinus infection. You say that your infection got worse after the surgery. You say that the infection damaged your bones and caused infection in your teeth that broke off. You also say that the lower side of your mouth has 2 teeth that also need to be removed.The Plan denied your request. The Plan says alveoloplasty are not listed as covered services. The Plan says extractions of erupted teeth are not listed as covered either.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-approve2 alveoloplasty and 9 extractions for erupted teeth.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific 
criteria are met. 
 
We looked at the file and Medicare rules. The file shows that you do not have a diagnosis of diabetes that 
meets the criteria for coverage of a therapeutic CGM. 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 continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a platelet rich plasma injection. 
 
You asked the Plan to pre-approve a platelet rich plasma injection. You say that when you had the same 
procedure in August it helped. You say that you want it again because it helps with your chronic knee pain. The 
Plan denied your request. The Plan says the necessity for the injection is not supported. 
 
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 a platelet rich plasma injection. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the effectiveness of platelet rich plasma injection to treat knee pain due 
to osteoarthritis has not been established. Our reviewer says that platelet rich plasma injections are considered 
experimental/investigational in nature and are not considered medically reasonable and necessary to treat 
chronic knee pain. 
 
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 platelet rich plasma injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a platelet rich plasma injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomographic angiography (CTA), heart, 
coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing 
(including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of 
venous structures, if performed) (CPT Code 75574). 
 
You asked the Plan to pre-approve the CTA scan. You say that you still have symptoms after your stress test 
done. You state you have tightness in your chest and heart, fluttering with palpitations each day. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 the CTA scan. Our physician reviewer 
found this test is not covered and is not considered standard 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 CTA scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomographic angiography (CTA), heart, coronary arteries and bypass grafts 
(when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac 
structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) 
(CPT Code 75574).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture. 
 
You asked the Plan to pre-approve the upper partial denture. You say that the previous bridge does not work. 
You say that a new bridge that functions is necessary. The Plan denied your request. The Plan says the service 
is only covered once every 5 years. 
 
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, you also have a maximum benefit of 
one partial denture every 5 years. You received an upper partial denture on February 13, 2017, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the upper partial 
denture.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ure-na. 
 
You asked the Plan to pre-approve the Ure-na. You say that the Ure-na is medically necessary to improve the 
member's condition and reduce readmission. The Plan denied your request. The Plan says the requested oral 
nutritional product is not a covered benefit under the member's Medicare benefit plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.  
 
The items you asked the Plan to pre-approve are nutritional supplements. Therefore, we decided that the Plan 
does not have to pre-approve Ure-na.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance services provided. 
 
You asked the Plan to pay for the non-emergency ambulance services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice for 
this date of service. 
 
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 the non-emergency ambulance services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair ramp. 
 
You asked the Plan to pre-approve the wheelchair ramp. You say that the enrollee has difficulty in using the 
stairs and may fall with the result of a serious injury. The Plan denied your request. The Plan says Medicare 
rules say a wheelchair ramp is considered a convenience item and not medical equipment. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
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. Therefore, we 
decided that the Plan does not have to pre-approve wheelchair ramp.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic shoes. 

You asked the Plan to pre-approve the diabetic shoes. You say that you would like reconsideration because the 
supplies are medically necessary. The Plan denied your request. The Plan says the submitted documentation 
does not support that the member meets Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that if criteria are not met, the therapeutic shoes, 
inserts and/or modifications will be denied as non-covered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the diabetic shoes have not been met. Specifically, the submitted documentation does not show that 
the certifying physician has documented a covered indication or a need for diabetic shoes. The documentation 
also does not show that an evaluation or assessment has been done. Therefore, we decided that the Plan does 
not have to pre-approve diabetic shoes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe occipital nerve injection (64405, 20553).You asked the Plan to pre-approvethe occipital nerve injection. You say that you suffer from chronic migraines and use to get the nerve blocks every month. It was working for you and you are not sure what the Plan wants you to do.The Plan denied your request. The Plan saysoccipital nerve block is considered experimental and investigational for the treatment of 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. The rules also say that experimental and investigational devices are not covered.We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occipital nerve injection have not been met.Therefore, we decided that the Plan does not have to pre-approvethe occipital nerve injection (64405, 20553).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 7, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. 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. 
 
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 
laboratory 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 laboratory services provided on July 7, 2020.