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

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental item. You say that you only need a new lower denture. You say 
that you lost your lower denture. You also say that you need a new pair. The Plan denied your request. The 
Plan says coverage for dentures is limited to once every 5 plan years. The Plan says that the frequency limit has 
been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and complete lower denture is listed as 
a covered service, the frequency limit has been reached. The record shows that the Plan paid for a complete 
lower denture that you received on June 10, 2019. Therefore, we decided that the Plan does not have to pre-
approve a complete lower denture (D5120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

You asked the Plan to pay for the automatic external defibrillator. You say that you would like reconsideration 
because your records show that this Plan is the primary payer. The Plan denied your request. The Plan says this 
Plan is the secondary payer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested 
that the provider bill the member's primary insurance. As the secondary insurer, the Plan cannot be held 
responsible for the automatic external defibrillator until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for the automatic external defibrillator 
(K0606) provided on August 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

You asked the Plan to pre-approve a heavy duty power operated vehicle. You say that the requested item would 
improve your quality of life and make maneuvering around your home more convenient. The Plan denied your 
request. The Plan says the rules for a heavy duty power operated vehicle have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that a Heavy Duty power operated vehicle is covered for a 
beneficiary weighing 285?450 pounds.  
 
The file shows that your weight is less than 285 pounds. This means that Medicare rules for coverage of a 
heavy duty power operated vehicle have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a power operated vehicle, Group 1 Heavy Duty (K0801).
Appeal type: Practitioner Services
Decision: Unfavorable

You asked the Plan to pre-approve arthrodesis, sacroiliac joint. You say that this ailment is creating further 
complications with your way of life. The Plan denied your request. The Plan says sacroiliac joint fusion is 
considered investigational for the enrollee's condition. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve arthrodesis, sacroiliac joint. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the medical records show that the patient has degenerative low back and hip 
pain. There is a negative faber test documented for sacroiliac joint pain. Sacroiliac joint fusion is not medically 
needed and not likely to be beneficial with a negative faber test. It also remains experimental for degenerative 
back 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 arthrodesis, sacroiliac joint. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve arthrodesis, sacroiliac joint.
Appeal type: Practitioner Services
Decision: Unfavorable

You asked the Plan to pre-approve the OON surgical consultation. You say that you are being recommended to 
have an open hernia repair, and you would prefer to do the laparoscopic which has a shorter recovery. You 
wish to be seen by a doctor who performed a laparoscopic surgery on your spouse, as you believe that this 
other provider would be willing to use this approach. The Plan denied your request. The Plan says there are 
other surgeons in your network/medical group who can provide a second opinion on your condition and 
consider open versus laparoscopic surgery. As the second opinion is available in your network, the OON 
referral is not necessary. 
 
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 general surgery consultation to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

You asked the Plan to pre-approve CT of the thorax. You say that the repeat CT chest will help determine the 
treatment plan for this member. The Plan denied your request. The Plan says follow-up CT chest is 
recommended after 3-6 months, then 18-24 months if stable. 
 
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 CT of the thorax. Our reviewer says 
that the review has determined that the requested CT is not medically reasonable or necessary. Our physician 
reviewer found follow-up CT chest is recommended after 3-6 months, then 18-24 months if 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 CT of the thorax have not been met. Therefore, we decided that the Plan does 
not have to pre-approve computed tomography (CT) of the thorax (71250).
Appeal type: Practitioner Services
Decision: Unfavorable

You asked the Plan to waive the coinsurance for the Part B drug. You say that you should not be charged the 
coinsurance because you had met your maximum out-of-pocket amount. The Plan denied your request. The 
Plan says they mistakenly applied $42.83 as the cost share and not the correct amount of $724.32. The Plan is 
not going to reprocess the claim. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for each in-network Medicare-covered Part B drug.  
 
You have been asked to pay $42.83 which is less than the standard 20% of the allowed amount for the Part B 
drug. The allowed amount is $3,621.58. The record shows you had only met $6,026.59 of your maximum out-
of-pocket amount. The Part B drug falls within the "Medicare Part B Prescription Drugs" benefit category.  
 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the Part B drug provided on August 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

You asked the Plan to pre-approve a CGM. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of a CGM 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

You asked the Plan to waive the coinsurance for the iron infusions. You say that you were only at the 
appointment for 15 minutes for an iron infusion at the provider's office. The Plan denied your request. The Plan 
says you have been asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B covered drugs at an in-network PCP's office, specialist's office, and pharmacy.  
 
You have been asked to pay $108.46 which is 20% of the allowed amount for the iron infusions on each date of 
service. The allowed amount is $542.30. ($542.30 x 20% = $108.46). ($108.46 x 2 = $216.92). The iron 
infusions fall within the "Medicare Part B prescription drugs" benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the iron infusions provided from November 5, 2020, to November 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, resin-
based composites, and extractions. You say that you would like these services to be covered. The Plan denied 
your request. The Plan says these services were rendered by an OON provider. The Plan also says that services 
performed by an OON provider are not covered because your healthcare plan does not have OON 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, you are responsible for 100% of the 
cost for dental services rendered by an OON provider. The record also shows that you did not contact the Plan 
prior to the date of service to verify the provider's eligibility. Therefore, we decided that the Plan does not have 
to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, two anterior resin-based 
composites, two posterior resin-based composites, and two extractions provided on October 2, 2020 by an 
OON provider.
Appeal type: Testing
Decision: Favorable

You asked the Plan to pre-approve a nuclear stress test of the heart. You say that you would like the plan to 
reconsider their 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 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 a nuclear stress test of the heart. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found you have a known abdominal aortic aneurysm. You have significant peripheral 
vascular disease that indicates that a treadmill stress test is unlikely to be successful. Based upon the totality of 
the medical records provided, it is medically reasonable and necessary for you to undergo a nuclear stress test 
for preoperative clearance for the planned procedure. Therefore, you meet criteria for the requested procedure. 
 
Review of the file shows that the plan uses Local Coverage Determination (LCD) L34324 to support their 
denial. However, this LCD is not valid for the enrollee's home state of South Carolina. Therefore, we cannot 
use LCD L34324 to substantiate our decision. 
 
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 nuclear stress test of the heart have been met. Therefore, we decided that the 
Plan has to pre-approve a nuclear stress test of the heart.  
 
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 the outpatient visit to be provided by an OON provider. 
 
You asked the Plan to pre-approve the outpatient visit. You say that you would like reconsideration because 
you need to be seen by the hospital that performed the initial service. The Plan denied your request. The Plan 
says there are network providers available to render this service. 
 
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 
the outpatient visit to be provided by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee can be treated at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the submitted medical records do not show 
that you have documented skilled nursing or therapy needs. You appear to have reached a plateau in your level 
of function.  Your care needs at this point are custodial and 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

You asked the Plan to pre-approve the SNF services. You say that you do not have a prosthetic yet. You say 
that your left leg needs to be strengthened and your upper body strength in your arm is fairly weak at this point 
because you have been in the hospital for a time. You say that rehabilitation will help you to build up your 
muscles. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for 
admission to a SNF. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 medically necessary. Our physician reviewer found that, based on the medical 
records, you have stabilized medically and you are ready for discharge from the hospital. You do not require 
skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further 
rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to 
improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care 
than a skilled nursing facility. You do not have any parental medication; complex wound care or nutrition 
given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical 
problems. Your physical function is at your new baseline and you can receive services at a lower level of care. 
Admission to a SNF for inpatient skilled rehabilitation services is not medically necessary. You have been 
receiving skilled rehabilitation services in the hospital without meaningful improvement. 

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 SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2752) for tooth #18. 
 
You asked the Plan to pre-approve the crown. You say that you would like this service to be approved. The 
Plan denied your request. The Plan says tooth #18 has a clinically unacceptable root canal fill. 
 
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 crown 
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 crown. Our reviewer says that the 
crown for tooth #18 is not medically reasonable and necessary. Our physician reviewer found the enrollee 
presented with a request for a crown replacement for tooth #18. The tooth was previously endodontically 
treated and has an existing crown. The crown does not have a clear defect or recurrent decay.  Our reviewer 
found that the endodontic fill does appear to be short in each canal, with a recurrent infection likely on the 
mesial root as determined by a radiolucency seen on the x-ray. A crown, either initial placement or a 
replacement crown, should not be placed on a tooth with an inadequate root canal fill and/or periapical 
infection. The Plan states that the endodontic fill should be sufficiently close to the apex so that a seal is 
achieved, and in this instance the fill is inadequate and has allowed a recurrent infection to occur. Our 
physician reviewer also found that given the radiographic appearance of #18, there would be no necessity for 
replacement of the existing crown 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 crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2752) for tooth #18.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crowns for tooth #5 and core buildup, including any pins 
when required for tooth #5 provided on July 6, 2020. 
 
You asked the Plan to pay for the crown for tooth # 5 and core buildup for tooth #5. You say that you would 
like these services to be covered. The Plan denied your request. The Plan says your crowns benefit had been 
satisfied and the frequency limitation had been exceeded. The Plan also says that core buildup is not 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, core buildup, including any pins when 
required is not among those covered under this benefit. The contract says that crowns are limited to two 
procedures per calendar year. The record shows that you received three crowns on July 6, 2020, two of which 
were covered by the Plan, and your crowns benefit had been exhausted. Therefore, we decided that the Plan 
does not have to pay for the crowns for tooth #5 and core buildup, including any pins when required for tooth 
#5 provided on July 6, 2020.