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

 
We decided that the Plan does not have to pre-approve core buildup (D2950) and a crown (D2740). 
 
You asked the Plan to pre-approve the core buildup and crown. You say that you would like reconsideration 
because the member has a previously treated root canal and post tooth which requires replacement. The Plan 
denied your request. The Plan says the requested services are 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 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 core 
buildup (D2950) and a crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued coverage of a continuous positive airway 
pressure (CPAP) machine. 
 
You asked the Plan to pre-approve the continued coverage of a CPAP machine. You say that you have a 
diagnosis of obstructive sleep apnea and the records provided support the need for a continued use of a CPAP 
machine. The Plan denied your request. The Plan says the records do not show that the enrollee's doctor has 
seen her since she started using the machine, documenting that the enrollee has benefitted from the machine. 
 
The Plan must follow Medicare rules. Medicare rules say that continued coverage of a PAP device beyond the 
first three months of therapy requires that the treating practitioner conducts a clinical re-evaluation and 
document that the enrollee is benefitting from PAP therapy.  
 
We looked at the file and Medicare rules. While the records provided did show objective evidence of adherence 
to use of the PAP device, they did not show an in-person clinical re-evaluation by the treating practitioner with 
documentation that symptoms of obstructive sleep apnea are improved.   
 
 
 
 
 
 
 
Based on this information, we decided that Medicare rules for coverage of the continued coverage of a CPAP 
machine have been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage 
of a continuous positive airway pressure (CPAP) machine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you had surgery and need foot orthotics. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crowns (D6750) for tooth #'s 23 & 26 and 
pontics (D6240) for tooth #'s 24 & 25. 
 
You asked the Plan to pre-approve the retainer crowns and pontics. You say that you are unable to eat and 
swallow because your teeth are moving. The Plan denied your request. The Plan says bridges are only covered 
to replace one anterior tooth. 
 
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 retainer 
crowns and pontics 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 retainer crowns and pontics. Our 
reviewer says that these services are not medically necessary. Our physician reviewer found the abutment teeth 
are inadequate to act as abutment teeth due to lack of adequate bone support and a bridge as requested is not 
reasonable or medically necessary.  Plan provisions also limit bridges, even where feasible, to where there is 
only one missing anterior tooth. 
 
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 retainer crowns and pontics have not been met. Therefore, we decided that 
the Plan does not have to pre-approve retainer crowns (D6750) for tooth #'s 23 & 26 and pontics (D6240) for 
tooth #'s 24 & 25.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you 
must receive care from in-network providers with the exception of emergency or urgent 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 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 the 
requested physician's services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT Scan of the heart (75571). 
 
You asked the Plan to pre-approve the CT Scan. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this service is not covered by Medicare as a 
screening test. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the CT Scan, is being requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-
approve a CT Scan of the heart (75571).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300), an F3 to F5 
upgrade, a functional reach tool, and an LED light kit (K0108x3). 
 
You asked the Plan to pre-approve the power seat elevation system, the accessories to turn a group 3 into a 
group 4 power wheelchair, and the LED light kit. You say that the records provided support the need for the 
requested items. The Plan denied your request. The Plan says the items in dispute are non-covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home. The rules also say that for equipment to be covered, it must primarily serve 
a medical purpose.   
 
 
 
The power seat elevation system in dispute is not considered primarily medical in nature and are non-covered 
by Medicare. Group 4 power wheelchairs include features that are not needed for use in the home, and they are 
therefore not considered medically necessary. The F3 to F5 upgrade and the functional reach are accessories 
which would alter your existing Group 3 wheelchair into a Group 4 power wheelchair. These features are not 
considered to be needed for use in the home. The LED kit being requested does not primarily serve a medical 
purpose. 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 a power seat elevation system 
(E2300), an F3 to F5 upgrade, a functional reach tool, and an LED light kit (K0108x3).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Computed Tomography (CT). 
 
You asked the Plan to pre-approve a Computed Tomography, cervical spine (72125). You say that you and 
your physician would like a CT scan to clarify your condition. The Plan denied your request. The Plan says 
your records do not support medical necessity for a CT. 
 
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 Computed Tomography, cervical spine 
(72125). Our reviewer says that the service is not medically necessary. Our physician reviewer found the case 
file does not include documentation of a more recent medical evaluation. The documentation is insufficient to 
demonstrate that a CT scan of the cervical spine is medically reasonable and necessary for the enrollee in this 
case.  
 
We looked at this physician's review, the file, and Medicare rules. There are no recent medical records 
supporting medical necessity for a CT scan. Based on this information, we decided that Medicare rules for 
coverage of Computed Tomography, cervical spine (72125) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Computed Tomography (CT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that the previous 
dentist gave you partial dentures that are not working. You also say that the teeth in the front on both sides are 
getting loose, and you are in a lot of pain. The Plan denied your request. The Plan says these services exceed 
the maximum count allowed per period. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, maxillary partial denture (D5213) and 
mandibular partial denture (D5214) are each limited to one procedure every five plan years. The record shows 
that you received a maxillary partial denture (D5213) and a mandibular partial denture (D5214) on February 
10, 2017, and your maxillary partial denture (D5213) and mandibular partial denture (D5214) benefits have 
been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture 
(D5213) and a mandibular partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural injection. 
 
You asked the Plan to pre-approve epidural injections. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for these injections is correct, because Medicare does not 
consider these injections to be medically reasonable and necessary. 
 
The Plan follows Medicare rules. Medicare rules say that it is not considered medically reasonable and 
necessary to perform mor than 2 epidural injections in a single setting. 
 
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 epidural injections. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested epidurals. Our physician reviewer found 
the enrollee underwent a total of 3 right lumbar transforaminal epidural steroid injections on June 23, 2020 
with good pain relief. Therefore, based upon the submitted documentation it is not medically reasonable and 
necessary for the enrollee to have a second series of 3 epidural steroid injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural injections have not been met. Therefore, we decided that the Plan does 
not have to pre-approve epidural injection.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested MRI. 
 
You asked the Plan to pre-approve the MRI. The Plan denied your request. The Plan says the enrollee must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan. 
 
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 the 
requested MRI.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that the enrollee is in a lot of pain. The Plan 
denied your request. The Plan says this service is not listed as 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 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 
core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve dental code D7250. 
 
You asked the Plan to pre-approve dental code D7250. You say that the requested dental code D7250 is 
medically necessary. The Plan denied your request. The Plan says that the requested dental code D7250 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 dental code 
D7250 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 dental code D7250. Our reviewer says 
that the requested dental code D7250 is medically necessary. Our physician reviewer found the request is for 
removal of the roots of tooth #30 under code D7250.  This code is reserved for situations where the roots 
remain in the bone and require surgical procedures involving bone cutting to be able to extract the remaining 
tooth. The ADA Guide to extractions - Teeth and Remnants provides a flow chart to allow selection of the 
proper code for extraction of tooth remnants.  In this case, the radiograph indicates the two remaining roots are 
submerged and encased, but not covered, in bone.  There does not appear to be a reasonable method of 
removing the tooth without cutting of the surrounding bone. The flow chart from the ADA indicates where 
there are residual roots (no coronal structure present) and that bone removal is necessary, then code D7250 is 
appropriate.  In this case the requested code is correctly applied to the situation as per the ADA 
recommendations. 
 
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 dental code D7250 have been met. Therefore, we decided that the Plan has to 
pre-approve dental code D7250.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code E1399. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings are necessary for 
treatment of your lymphedema. The Plan denied your request. The Plan says you do not have a qualifying 
wound. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code E1399 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means 
that the enrollee does not have a medical condition for which compression stockings can be covered or paid for 
by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings 
identified with code E1399.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve reconstructive surgery for poorly fitting dentures, for 
the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says this service is not covered under Medicare or the Health Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that 
are not covered or paid for by Medicare. The member does not meet Medicare guidelines for the requested 
dental services to further manage ill-fitting dentures. Therefore, we decided that the Plan does not have to pre-
approve reconstructive surgery for poorly fitting dentures, for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a continuous positive airway pressure device (CPAP). 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says that a current sleep study is required before requesting this device. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 device. Our reviewer says that the 
requested device is considered medically reasonable and necessary in this case. Our physician reviewer found a 
trial of auto-titrating CPAP is reasonable and necessary. The records confirm obstructive sleep apnea on a 
home PSG in 2018. You were intolerant of CPAP because of heartburn; this could be addressed. A repeat trial 
is warranted. 
 
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 device have been met. Therefore, we decided that the Plan has to pre-
approve a continuous positive airway pressure device (CPAP).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two core buildups, including any pins when required 
(D2950 x2). 
 
You asked the Plan to pre-approve the core buildups. The Plan denied your request. The Plan says this 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 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 two 
core buildups, including any pins when required (D2950 x2).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve Magnetic Resonance Imaging (MRI) of the lower extremity 
(73721). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says that coverage rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
MRI is medically necessary. Our physician reviewer found the enrollee has chronic pain in the right knee. A 
treatment plan is documented which failed. Instability is not likely to be diagnosed on plain x-rays. The MRI is 
appropriate. 
 
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 MRI have been met. Therefore, we decided that the Plan has to pre-approve 
Magnetic Resonance Imaging (MRI) of the lower extremity (73721).  
 
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.