Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Adakveo. 
 
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 sickle cell thalessemia 
without crisis. He has been receiving apheresis therapy but currently has insufficient venous access for an 
apheresis machine and a port catheter is not recommended for him. He has had no crisis in the past 12 months. 
The records do not show that he is having vasoocclusive episodes, suffering sickle cell crisis recently, or failing 
hydoxyurea. The notes do not clearly describe the reason for not being a candidate for a port catheter. The 
notes also state he does not have access to monthly Adakveo. The services are not reasonable or medically 
necessary for the enrollee based on the submitted documentation. 
 
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 Adakveo.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the ResMed air mini travel continuous positive airway 
pressure device (CPAP) (E1399). 
 
You asked the Plan to pre-approve the mini travel CPAP. You say that you are appealing the denial of the mini 
travel CPAP. You were denied because you have an approved similar equipment delivered by you had returned 
it in February because it was not the equipment you needed. The Plan denied your request. The Plan says the 
equipment requested is a mini version of a CPAP that is used to travel. This item is for use outside the home (to 
travel) and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
The requested item at issue is a mini CPAP that is used for traveling. This item is not for use inside of the home 
and does not meet the definition of durable medical equipment. Therefore, we decided that the Plan does not 
have to pre-approve the ResMed air mini travel continuous positive airway pressure device (CPAP) (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Foot, insert, removable, formed to patient foot, each 
(L3030) 
 
You asked the Plan to pre-approve foot orthotics. You say that you are appealing the denial if the foot arch 
support. The Plan denied your request. The Plan says the enrollee has no medical condition that meets the 
Medicare coverage criteria and does not have a brace that is integral with a shoe. 
 
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, insert, removable, formed to 
patient foot, each (L3030)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (code D0140), the intraoral 
periapical x-ray (code D0220), and the rebond/ re-cement of a crown (code D2920) you received on November 
17, 2021. 
 
You asked the Plan to pay for the limited oral evaluation (code D0140), the intraoral periapical x-ray (code 
D0220), and the rebond/ re-cement of a crown (code D2920). You say that these services were needed due to 
an emergency where your crown broke off. The Plan denied your request. The Plan says these services are not 
covered under your dental 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. The Plan's dental benefit 
includes coverage only for the following dental services: periodic oral exams, periodontal exams, 
comprehensive dental exams, bitewing x-rays, cleanings, and anesthesia.The limited oral evaluation (code 
D0140), the intraoral periapical x-ray (code D0220), and the rebond/ re-cement of a crown (code D2920) are 
not listed as covered services.  This means that these are not covered for any reason, including emergencies. 
 
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 the 
limited oral evaluation (code D0140), the intraoral periapical x-ray (code D0220), and the rebond/ re-cement of 
a crown (code D2920) you received on November 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional rides to other health care related locations. 
 
You asked the Plan to pre-approve additional rides. You say that you are currently receiving physical therapy 
services and cannot afford other transportation. The Plan denied your request. The Plan says additional 
coverage outside of your covered benefits is not able to be approved. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 36 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional rides to other health care related locations.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that the requested item is a necessity for 
your care. The Plan denied your request. The Plan says rules for coverage for a PMD have not been met. 
 
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 patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file does not show that your condition cannot be improved by a manual wheelchair. This means that 
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Group 1 standard power operated vehicle (K0800).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service 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 the Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this service is considered experimental and more research is needed to show its safety 
and efficacy for the patients diagnosis. 
 
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 Intracept procedure. have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
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 this is medically necessary. The 
Plan denied your request. The Plan says this is not covered. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor. 
 
You asked the Plan to pre-approve a Dexcom G6. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results and have had an in-person visit with their treating physician to assesses 
adherence to their CGM regimen and diabetes treatment plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
Dexcom G6 have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom 
G6 continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a USB charger. 
 
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. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 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 USB charger.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a queen mattress and base. 
 
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. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 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 queen mattress and base.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve oxygen concentrator and portable oxygen. 
 
You asked the Plan to pre-approve oxygen concentrator and portable oxygen. You say that you would like the 
plan to reconsider their denial. The Plan denied your request. The Plan says the documentation shows that the 
enrollee has the requested items. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has oxygen equipment. The requested oxygen concentrator and portable 
oxygen serves the same purpose as the enrollee's current equipment. The enrollee has been using oxygen 
equipment for more than 36 months. The reasonable useful lifetime for oxygen equipment is five years. The 
documentation does not support that the enrollee's current oxygen equipment is damaged beyond repair, stolen, 
or lost. There is no documentation that the enrollee is unable to use their current equipment. Therefore, we 
decided that the Plan does not have to pre-approve oxygen concentrator and portable oxygen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup for continuous positive airway pressure 
(CPAP) machine. 
 
You asked the Plan to pre-approve a battery backup for CPAP machine. 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 a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. 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 battery backup for continuous positive airway pressure 
(CPAP) machine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you do not have any transportation to 
or from your dialysis, which you receive three time a week. The Plan denied your request. The Plan says you 
have exhausted the established benefit or 24 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).
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 supplies after surgery. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) device and 
supplies. 
 
You asked the Plan to pre-approve CPAP device and supplies. You say that this is medically necessary. The 
Plan denied your request. The Plan says required clinical information was not received. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of continuous positive airway pressure 
(CPAP) device and supplies have been met. Specifically, no clinical information was received regarding 
whether the criteria for CPAP coverage, including a relevant sleep study, was provided.  Therefore, we decided 
that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) device and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3332). 
 
You asked the Plan to pre-approve foot orthotics. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says the requested 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 (L3332).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a USB charger accessory for a power wheelchair. 
 
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. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we 
decided that the Plan does not have to pre-approve a USB charger accessory for a power wheelchair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (70450) provided on February 11, 2022. 
 
You asked the Plan to pay for the CT scan (70450). You say that the enrollee had multiple exams on this date 
of service. You say that the attached reports support the level of service, and the claim should be reconsidered 
for processing. The Plan denied your request. The Plan says an appropriate modifier was not billed with this 
code edit. 
  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the CT scan (70450) provided on February 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutments (D6057) and abutment-supported 
crowns (D6058) for teeth #11-#15. 
 
You asked the Plan to pre-approve abutments and abutment-supported crowns. You say that these services are 
necessary. The Plan denied your request. The Plan says these services are not covered by your dental 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 
custom abutments (D6057) and abutment-supported crowns (D6058) for teeth #11-#15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you receive dialysis 3 times a week 
and do not have anyone to transport you there. You also say that it is important for you to have these trips since 
it is the only way for you to attend dialysis. The Plan denied your request. The Plan says you have exhausted 
the established benefit of 24 one-way trips. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
  
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide an additional 36 routine transportation trips. 
 
You asked the Plan to provide additional transportation. You say that you need additional transportation to get 
to your appointments. The Plan denied your request. The Plan says your plan covers a maximum of 36 trips per 
year. Additional trips are not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 36 trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide an additional 36 routine transportation trips.