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

We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve the dental item. You say that you were using a different dentist in 2019. 
You say that you needed an upper partial denture at the time but did not ever have it installed. You also say that 
you have no bottom molars and cannot eat correctly. The Plan denied your request. The Plan says partial 
dentures are covered once every 5 years. The Plan says that the benefit for a lower partial denture has been 
exhausted. 
 
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 dentures are a covered service, the 
frequency limit of once every 5 years has been exceeded. The record shows that a lower partial denture was 
previously paid for on March 16, 2019. Therefore, we decided that the Plan does not have to pre-approve a 
lower partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you need the items and are not able to 
pay for them. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Imfinzi. 
 
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 Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 
the services are not medically necessary. Our physician reviewer found the enrollee has completed 
chemotherapy with carboplatin/etoposide for extensive stage small cell lung cancer (SCLC) and has an 
increasing left adrenal mass. The documentation does not support that the use is safe and effective for the 
enrollee; therefore, Imfinzi is not reasonable or medically 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve Imfinzi.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process 
stabilization/distraction device, without open decompression or fusion, including image guidance when 
performed, lumbar; single level (CPT Code 22869). 
 
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not necessary. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the device is experimental. More research is needed to show the safety and efficacy of the 
procedure. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open 
decompression or fusion, including image guidance when performed, lumbar; single level (CPT Code 22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for sensors, transmitters, and receiver for use with an interstitial 
continuous glucose monitor. 
 
You asked the Plan to pay for the sensors, transmitters, and receiver. You say that you need these supplies. The 
Plan denied your request. The Plan says the supplies are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that these codes are not used to bill for supplies used 
with a covered therapeutic continuous glucose monitor. 
 
The supplies are considered to be a non-therapeutic CGM device per Medicare guidelines and are therefore 
non-covered. Therefore, we decided that the Plan does not have to pay for sensors, transmitters, and receiver 
for use with an interstitial continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthroscopy, shoulder, surgical, with rotator cuff repair 
(29827). 
 
You asked the Plan to pre-approve the arthroscopic rotator cuff repair. You say that the medical records 
provided will show proof of medical necessity. The Plan denied your request. The Plan says this procedure is 
experimental and investigational. 
 
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 arthroscopic rotator cuff repair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthroscopy, shoulder, surgical, with rotator cuff repair (29827).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that because of medical conditions you 
need a total electric hospital bed. The Plan denied your request. The Plan says total electric hospital beds are 
not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network provider. 
 
You asked the Plan to pre-approve out of network urology services. You say that your physician told you it 
would take a lot longer to be seen by anyone else nearby. The Plan denied your request. The Plan says the 
service is available in-network. 
 
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 medical services to be provided by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve CT scan. You say that the enrollee is a current smoker with a 30 pack-year 
smoking history. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because this CT scan is not applicable for lung cancer screening and a low-dose CT scan would be 
more appropriate for screening purposes. 
 
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, CT scan, is being requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. However, a low-dose computed tomography (LDCT) test may be 
covered for the requested screening purposes. Therefore, we decided that the Plan does not have to pre-approve 
a computed tomography (CT) scan of the chest.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two (2) dental extractions (D7210) to be performed by 
an oral surgeon. 
 
You asked the Plan to pre-approve the dental services. You say that the teeth are infected and painful, and you 
are unable to eat. The Plan denied your request. The Plan says services must be performed by a participating 
general dentist. 
 
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. 
 
While you may have been referred to an oral surgeon by a general dentist as part of that provider's professional 
obligation to provide or recommend what they felt to be appropriate treatment, the requested services are not 
included in your contract benefit. Your contract with the Plan only covers dental services when they are 
performed by a participating general dentist. Dental services performed by an oral surgeon are not covered. 
Therefore, we decided that the Plan does not have to pre-approve two (2) dental extractions (D7210) to be 
performed by an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a Lingraphica Touch Talk speech-generating device (SGD). 
 
You asked the Plan to pre-approve the SGD. You say that this is the most medically appropriate device for 
assisting this enrollee with communication. The Plan denied your request. The Plan says that the enrollee's 
speaking needs can be met through natural communication methods and there has not been an evaluation ruling 
out other forms of treatment. 
 
The Plan follows Medicare rules. Medicare rules say that an SGD is covered when the above referenced criteria 
have been met.  
 
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 SGD. Our reviewer says that the 
requested SGD is medically reasonable and necessary based on the LCD criteria. Our physician reviewer found 
the patient is a 72-year-old male with diagnosed aphasia. The provided documentation reveals that his natural 
speech is not efficient for functional communication independently. A request for a Lingraphica Touch Talk 
device was made after a trial with this device showed he was significantly benefiting from the device. Based on 
the evaluation by the speech therapist and physician documentation, other devices would be inferior and would 
not meet the patient's needs. 
 
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 SGD have been met. Therefore, we decided that the Plan has to pre-approve 
a Lingraphica Touch Talk speech-generating device (SGD).  
 
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 peripheral nerve injections (64450). 
 
You asked the Plan to pre-approve peripheral nerve injections. You say that you need this because you cannot 
feel your left leg. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 peripheral nerve injections. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record does not show that you have an evidence-based indication for 
peripheral nerve blocks. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of peripheral nerve injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve peripheral nerve injections (64450).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide for bathing. 
 
You asked the Plan to pre-approve the services. You say that COVID-19 had greatly affected you and it has 
become too difficult to bathe on your own. The Plan denied your request. The Plan says the records indicate 
that you are not receiving skilled nursing services at home. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our physician reviewer 
found the records do not show that skilled nursing services are required to effectively provide treatment, care, 
and/or services in order to improve your condition, to establish/perform a maintenance program to maintain 
your condition and/or prevent deterioration. The records do not show that skilled therapy services are required 
to effectively provide treatment, care, and/or services in order to improve your level of function, to 
establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. As 
you do not require skilled nursing or skilled therapy services you do not meet the definition of home health aide 
services per Section 50.2 and home health aide services are not reasonable and necessary to the treatment of 
your illness or injury by the skilled professional staff. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide for bathing.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Vitamin D hydroxy testing rendered on March 30, 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 screening tests are not covered. 
 
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, Vitamin D hydroxy, was 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 pay 
for the Vitamin D hydroxy testing rendered on March 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the deep sedation and therapeutic drug injection to be 
provided with an approved dental extraction. 
 
You asked the Plan to pre-approve the deep sedation and drug injection. You say that you are in pain and 
cannot chew on the left side. This treatment is medically necessary. The Plan denied your request. The Plan 
says the extraction was approved, but the requested sedation is not covered by the 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 the 
deep sedation and therapeutic drug injection to be provided with an approved dental extraction.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda (pembrolizumab) injections. 
 
You asked the Plan to pre-approve the Keytruda. You say that you believe that this treatment is medically 
necessary and could help this patient. The Plan denied your request. The Plan says this cannot be covered as 
first line treatment for this condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Keytruda. Our reviewer says that 
the requested use of Keytruda is not shown to be medically reasonable and necessary. Our physician reviewer 
found this review relates to a request for Keytruda as first line monotherapy for an 87-year-old man with 
pleural mesothelioma. The requested use is not FDA approved. Keytruda is not supported for this use in any of 
the CMS approved compendia. This reviewer did not find any supporting citations in a PubMed search. As 
such, the Medicare rules for coverage of Keytruda are not met.  
 
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 Keytruda have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda (pembrolizumab) injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a negative pressure wound therapy (NPWT) pump and 
supplies to be provided by an out of network (OON) provider. 
 
You asked the Plan to pre-approve the OON NPWT equipment. You say that this is medically necessary due to 
the non-healing wound. The Plan denied your request. The Plan says network providers are able to provide the 
requested equipment. There is no need for OON referral for 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 
a negative pressure wound therapy (NPWT) pump and supplies to be provided by an out of network (OON) 
provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bariatric size total electric hospital bed with rails and 
mattress. 
 
You asked the Plan to pre-approve the total electric hospital bed, rails and mattress.. You say that the bed is 
medically necessary. The Plan denied your request. The Plan says a total electric hospital bed is not a covered 
item. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a bariatric size total 
electric hospital bed with rails and mattress.