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

 
We decided that the Plan does not have to pre-approve an abutment-supported porcelain ceramic crown with 
custom abutment for tooth #14. 
 
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. 
 
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 an 
abutment-supported porcelain ceramic crown with custom abutment for tooth #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions in a hospital setting (D9240). 
 
You asked the Plan to pre-approve the extractions. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the requested service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental extractions in a hospital setting (D9240).
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 item 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 reveal that you have a personal mobility 
deficit but does not reveal that it impairs participation in mobility related activities of daily living in the home. 
The documentation does reveal that your mobility deficit is able to be helped by a walker, cane, and/or manual 
wheelchair. The documentation is not clear that you can safely maneuver the power operated vehicle in the 
home as there is no home assessment. The documentation does not support that the requested power 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ondansetron tab 4mg ODT for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not covered by Medicare for this condition. 
 
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 Ondansetron tab 4mg ODT 
for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on August 13, 2019. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was 
submitted after the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the services was not filed until September 16, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the services provided on August 13, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on August 5, 2020. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent 
or emergent, nor were they approved in advance. 
 
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 
services at issue. 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 a domiciliary, rest home visit provided on August 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis. 
 
You asked the Plan to pay for lumbar-sacral orthosis. You say that you are appealing with supporting 
documentation. The Plan denied your request. The Plan says the denial of payment for this item is correct, 
because the documentation submitted does not include proof of delivery for the item billed. 
 
The Plan must follow Medicare rules. Medicare rules say that proof of delivery may be required for a lumbar-
sacral orthosis to determine the payment amount due.  
 
We looked at the file and Medicare rules. The documentation submitted does not include valid proof of 
delivery for the billed item. Based on this information, we decided that Medicare rules for coverage of lumbar-
sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral 
orthosis.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to provide a Positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole 
body (78816). 
 
You asked the Plan to provide a PET/CT scan. You say that you need a PET scan because of your medical 
condition. The Plan denied your request. The Plan says the requested PET/CT would exceed allowed limit. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 provide a PET/CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found that the Plan was correct to deny per NCD 
220.6.17 as patient has had 3 previous pet scans. 
 
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 PET/CT scan have not been met. Therefore, we decided that the Plan does not 
have to provide a Positron emission tomography (PET) with concurrently acquired computed tomography (CT) 
for attenuation correction and anatomical localization imaging; whole body (78816).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services. 
 
You asked the Plan to pre-approve core buildup (D2950) on tooth 3. You say that the enrollee needs this dental 
service. The Plan denied your request. The Plan says D2950 is not listed on the enrollee's supplement dental 
plan. 
 
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 
dental services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator. 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 
the enrollee does not meet the criteria for coverage. Our physician reviewer found the enrollee has chronic 
obstructive pulmonary disease (COPD) with chronic hypoxic and hypercapnic respiratory failure. She is a 
potential candidate for BiPAP support during sleep. Medicare does not cover a ventilator when used as BiPAP. 
She has not yet tried BiPAP in the home setting and failure of BiPAP is not documented. The home ventilator 
is therefore not reasonable or medically necessary at this time. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
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 these services. You say that the inserts are needed due to foot pain radiating 
to your knee and hip. The Plan denied your request. The Plan says the services are not covered. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that this is necessary for the enrollee to walk again. The 
Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of the patient's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. While the patient does require physical therapy and occupational therapy 
services, the patient does not require an intensive inpatient rehabilitation therapy program. Care at the skilled 
nursing facility level appears to be more appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided 
June 17, 2020. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you are asking for 
an appeal. Fairness would be $50 per visit. The Plan denied your request. The Plan says the claim was 
processed with the correct copayment applied per the Evidence of Coverage. 
 
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 $90 
emergency room copayment for Emergency care.  
 
You have been asked to pay a $90 emergency room copayment for the emergency room services. The 
emergency room services fall within the Emergency care 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 emergency room services provided June 17, 2020.
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 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 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 there are no services at the LTACH that you require 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 to a lower level of care may be considered soon. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electrocardiogram with CPT code 93010 provided on 
June 2, 2020. 
 
You asked the Plan to pay for CPT code 93010. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient.  
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for the electrocardiogram with CPT code 93010 provided on June 2, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are still weak from a stroke that occurred on 
New Year's Eve. You say that your left-side arm and leg muscles are weak. You say that you cannot walk by 
yourself and need assistance to get out of bed. You say that you want to go to the requested facility because 
they do not have any COVID patients. The Plan denied your request. The Plan says the records do not show 
that the criteria for admission to an IRF have been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for left leg weakness and was diagnosed with a stroke. The enrollee's medical conditions are stable. 
There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation 
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental bridge (D2950, D6740, D6240) for teeth #3 to 
#5. 
 
You asked the Plan to pre-approve the bridge. You say that the service is medically necessary. The Plan denied 
your request. The Plan says bridges are not covered for the replacement of posterior teeth. 
 
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 
dental bridge (D2950, D6740, D6240) for teeth #3 to #5.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable neurostimulator/electro-acupuncture for 
the enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is an experimental/ investigational therapy. There are several evidence-based therapies that have not 
been documented as having been trialed. Therefore, the request is considered 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 the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an implantable neurostimulator/electro-acupuncture for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 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 enrollee does not meet the criteria for coverage. 
 
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 the enrollee does not use insulin three or more 
times per day with frequent dose adjustments. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer. 
 
You asked the Plan to pre-approve the device. You say that you would like reconsideration because this device 
is medically necessary. The Plan denied your request. The Plan says current medical literature indicates that 
this service is considered experimental and investigational as it is not identified as widely used and generally 
accepted for the proposed use. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device is experimental and more research is needed to show its safety and efficacy. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve the Vertiflex Superion Spacer.