Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller with harness and electronic
connection between two power systems for a power wheelchair (PWC).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that an expandable controller and electronic
connection are covered when specific criteria are met.
We looked at the file and Medicare rules. The services at issue are an expandable controller and harness and
electronic connection between two power options. The approved PWC includes three power options. There is
no need to control these power options through a joystick. 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 an expandable controller with harness and electronic connection between two power systems for a
power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor for the enrollee.
You asked the Plan to pre-approve an automatic blood pressure monitor. You say that the enrollee's blood
pressure is very bad. The Plan denied your request. The Plan says that this is not covered for the enrollee's
condition.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require
ABPM to confirm a diagnosis of hypertension.
The records do not show that this monitor is requested in the setting of home dialysis services, or that this
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation.
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor for the
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a nonstandard seat frame depth, 20 to less than 22
inches (E2203).
You asked the Plan to pre-approve a nonstandard seat frame. You say that the item is 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. Medicare rules say that for all adult manual wheelchairs (E1161, K0001,
K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009), payment for seat widths and/or seat depths of
15-19 inches is included in the payment for the base code. These seat dimensions should not be billed
separately.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a nonstandard seat frame have not been met. Therefore, we decided that the Plan does not have to
pre-approve a nonstandard seat frame depth, 20 to less than 22 inches (E2203).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve therapeutic continuous glucose monitor. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for these supplies is correct, because the enrollee only checks insulin once per day and only takes insulin once per day.
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 the enrollee does not 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. Based on this information, we decided that Medicare rules for coverage of therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
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 the enrollee does not require services at the LTACH that are not available at the acute
care hospital where they are currently receiving care. There are no services available at the LTACH that the
enrollee requires that are not available at the health care setting being offered by the health plan. The requested
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of
the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two bone replacement grafts for ridge preservation
(D7953 x2).
You asked the Plan to pre-approve the bone replacement grafts. You say that you need the bone grafting done
in order to receive the dental implant procedure. The Plan denied your request. The Plan says this service is not
covered under your benefit package.
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
bone replacement grafts for ridge preservation (D7953 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0364),
two bone replacement grafts for ridge preservation (D7953 x2), fixed partial denture sectioning (D9120), and
two endosteal implants (D6010 x2).
You asked the Plan to pre-approve the cone beam CT capture and interpretation, bone replacement grafts, fixed
partial denture sectioning, and endosteal implants. You say that your bridge is infected, and you urgently need
these services. The Plan denied your request. The Plan says these services are not covered under your benefit
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 a
cone beam CT capture and interpretation (D0364), two bone replacement grafts for ridge preservation (D7953
x2), fixed partial denture sectioning (D9120), and two endosteal implants (D6010 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
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. 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the submitted records show that you
have low back pain. The records do not document that you received any of the standard testing to support the
involvement of the SI joint in your pain. There is no documented physical exam of the SI joint or current
physical therapy. The records do not support that the SI joint injection is 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 a sacroiliac (SI) joint injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental abutment (D6057) and crown (D6059) received on September 2, 2020.
You asked the Plan to pay for a dental abutment and crown. You say that these items/services have already been approved. The Plan denied your request. The Plan says rules for payment have not been met.
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 services up to an annual maximum of $1,000. We looked at the case file and Medicare rules. The record shows that your annual dental benefit was exhausted in February 2020. The Plan contract states that after the annual maximum is exhausted any remaining charges are your responsibility. Based on this information, we decided that the Plan's rules for coverage of a dental abutment and crown have not been met. Therefore, we decided that the Plan does not have to pay for a dental abutment (D6057) and crown (D6059) received on September 2, 2020.
Your complaint about the Plan causing delays in treatment for two years is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre sensor kit and reader for the
enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the clinical information submitted did not establish these services as 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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee is not on insulin and therefore does not meet the requirements for a continuous glucose
monitor.
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 the Freestyle Libre sensor kit and reader for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (21030, 00170, 41899).
You asked the Plan to pre-approve the dental services. You say that the cyst removal at issue should be a covered service. The Plan denied your request. The Plan says the type of cyst involved is dental in nature and as a result the services are considered dental services and are not covered.
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. Therefore, we decided that the Plan does not have to pre-approve dental services (21030, 00170, 41899).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion interspinous spacer (22869, 22870).
You asked the Plan to pre-approve Superion interspinous spacer. 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. 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 Superion interspinous spacer. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found Superion indirect lumbar decompression would not be considered the
standard of care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as
medically reasonable and necessary for treatment of this enrollee's medical condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Superion interspinous spacer have not been met. Therefore, we decided that the
Plan does not have to pre-approve Superion interspinous spacer (22869, 22870).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a removal of residual tooth roots.
You asked the Plan to pre-approve the removal of residual tooth roots. You say that this service is for a broken
tooth cap. The Plan denied your request. The Plan says this service is not covered under your benefit 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 a
removal of residual tooth roots.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation.
You asked the Plan to pre-approve the hypoglossal nerve stimulation. You say that you would like
reconsideration because this service is medically necessary for your life threatening condition. The Plan denied
your request. The Plan says Medicare coverage criteria states that your BMI must be less than 35.
The Plan must follow Medicare rules. Medicare rules say that hypoglossal nerve stimulation is not reasonable
or necessary when your BMI is 35 kg/m2 or greater.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the hypoglossal nerve stimulation have not been met. Specifically, the record indicates that your
BMI is 39. Therefore, we decided that the Plan does not have to pre-approve hypoglossal nerve stimulation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi (J9173).
You asked the Plan to pre-approve Imfinzi. You say that the medication 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 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 Imfinzi. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found Imfinzi is indicated for the treatment of
non-small cell lung cancer, unresectable Stage III, without progression following concurrent platinum-based
chemotherapy and radiation therapy. There is no documentation regarding progression of the enrollee's
carcinoma following chemoradiation therapy. Therefore, the documentation does not support that Imfinzi is
medically reasonable and necessary for the enrollee in this case. The documentation does not support that
Imfinzi is safe and effective for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to
pre-approve Imfinzi (J9173).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered from March 15, 2020 to March 16, 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 procedure code 99232 is included in the global surgical period and codes 36558, 76937,77001 and 99152 are a duplicate claim.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that procedure codes 36558, 76937,77001 and 99152 were previously paid by the Plan on a separate claim for the same date of service. The rules say that postoperative services are included in the global surgical package. The file shows that procedure code 99232 was billed within 10 days of a minor surgical procedure billed with code 36558 on March 15, 2020. These services are included in the global surgical package. 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 pay for the services rendered from March 15, 2020 to March 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam CT scan (D0364) performed on July 24, 2020.
You asked the Plan to pay for a cone beam CT scan. You say that this procedure had to be performed as otherwise your provider would not have known how to proceed in your treatment. The Plan denied your request. The Plan says rules for payment have not been met.
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 pay for a cone beam CT scan (D0364) performed on July 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the medication is 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. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a foldable shower gurney.
You asked the Plan to pre-approve the shower gurney. You say that the enrollee is not able to use a shower
chair due to his condition. He requires a folding shower gurney to allow him to shower safely. The Plan denied
your request. The Plan says this is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
Review of the file shows that the requested gurney serves the same purpose as a shower chair, with additional
components due to this particular enrollee's condition. As such, we find that a shower gurney is similarly not
primarily medical in nature, as it is hygienic equipment. Therefore, we decided that the Plan does not have to
pre-approve a foldable shower gurney.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 21, 2020, by an OON provider.You asked the Plan to pay fora domiciliary or rest home visit and chronic care management services. You say that these services were provided in good faith to the enrollee.The Plandenied your request. The Plan says rules for payment have not been met.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 has network providers available who can provide the items/services at issuein this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on January 21, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-spinal chiropractic manipulations.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pre-approve non-spinal chiropractic manipulations.