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

We decided that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 30. 
 
You asked the Plan to pre-approve the dental service. You say that there is no interproximal contact between 
tooth # 30 and # 31. You say that the enrollee is experiencing a food impaction between these teeth. You also 
say that there is a periodontal pocket on the distal of # 30 due to lack of contact. The Plan denied your request. 
The Plan says that crowns to close gaps 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 and crowns are listed as covered, 
crowns to close gaps between two teeth are not among those covered under this benefit. Therefore, we decided 
that the Plan does not have to pre-approve a porcelain crown (D2740) for tooth # 30.
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 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 IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 your nursing, medical and rehabilitat ion needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a 
reasonable expectation that you 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that this service is medically necessary for 
your neck pain. The Plan denied your request. The Plan says there are in-network providers available for your 
medical needs. 
 
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 
chiropractic services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (64447) provided on March 30, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service.

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 64447 
has a bundled relationship with code 01402 and cannot be paid as billed. This code cannot be paid as a separate 
line item. 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 services (64447) provided on March 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee's family wants her to be transferred to 
this facility. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this provider is out-of-network with the Plan and the enrollee can be treated at an in-network skilled 
nursing facility. 
 
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 
skilled nursing facility (SNF) care to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120). 
 
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need 
additional transportation trips for medical appointments. The Plan denied your request. The Plan says you have 
exhausted your 2021 maximum 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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of 60 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 provide coverage for additional routine transportation trips (A0120).
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve intensity modulated radiation therapy (IMRT) services. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee will significantly benefit 
from receiving this treatment. The Plan denied your request. The Plan says that its effect on overall survival is 
reported to be uncertain. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that IMRT is a tool that clinicians can use when there is concern about sparing normal tissues 
from high dose exposure.  IMRT generally implies inverse planning algorithms, i.e. the physician determines 
radiation treatment parameters to maximize dose to the target and minimize dose to normal tissues, and the 
planning algorithm maximizes the adherence to these parameters by modifying the beam spatially and/or 
temporally. The National Comprehensive Cancer Network (NCCN) guidelines explicitly stated to consider 
hippocampal sparing IMRT in the setting of prophylactic brain radiation, while more recent (1.2022) guidelines 
state that IMRT may be considered. Given the guidelines recognition of hippocampal sparing IMRT as a 
consideration in the setting of prophylactic brain radiation, and at least on randomized trial demonstrating a 
benefit, the treatment is medically necessary in accordance with accepted standards of care. 
 
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 requested services have been met. Therefore, we decided that the Plan has to 
pre-approve intensity modulated radiation therapy (IMRT) services.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high-frequency chest-wall oscillation system (E0483) 
to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve a high-frequency chest-wall oscillation system. You say that the requested 
item is a necessity for your care. The Plan denied your request. The Plan says rules for out-of-network care 
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 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 item at issue in this appeal. We found no exception that would require the Plan 
to pre-approve this item.  

Therefore, we decided that the Plan does not have to pre-approve a high-frequency chest-wall oscillation 
system (E0483) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an out of network (OON) 
Orthopedic Oncologist. 
 
You asked the Plan to pre-approve the OON office visit. You say that the enrollee was referred to the requested 
OON provider because of expertise in the area of Orthopedic Oncology and this specialty not being part of the 
Plan's network. The Plan denied your request. The Plan says they have a network orthopedic oncology 
specialist that is able to treat and manage the enrollee's condition.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 OON office visit. Our reviewer says 
that the criteria for coverage of OON care have not been met. Our physician reviewer found the completion of 
a workup/biopsy, if needed, can be done by an in-network provider. Only if a diagnosis of Sarcoma is made 
would a referral to an OON tertiary care center be considered for medical necessity.  
 
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 OON office visit have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an office visit with an out of network (OON) Orthopedic Oncologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amounts for the scaling and root planing 
(D4341 x 4) provided from June 1, 2021, to June 3, 2021. 
 
You asked the Plan to waive the cost share amounts for the scaling and root planing. You say that the service 
was not covered correctly. You also say that the service was not charged correctly by the dental office. The 
Plan denied your request. The Plan says there is a 50% coinsurance for scaling and root planing after the $100 
deductible has 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.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the scaling and root planing have not been met. Specifically, the record shows that prior to June 1, 
2021, the $100 deductible had not been met. Once the deductible has been met, there is a 50% coinsurance for 
scaling and root planing. The deductible and coinsurance are contractual obligations that you agreed to when 
you signed up for the plan. Therefore, we decided that the Plan does not have to waive the cost share amounts 
for the scaling and root planing (D4341 x 4) provided from June 1, 2021, to June 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic computed tomography (CT) scan of the 
chest. 
 
You asked the Plan to pre-approve a CT scan of the chest. You say that the requested imaging service is 
medically necessary. The Plan denied your request. The Plan says the requested CT scan of the chest is not 
medically reasonable and necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the chest. Our reviewer 
says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found the 
review indicates that the enrollee is an 83-year-old with a history of memory loss, hypertension, 
hypersensitivity, hypothyroidism and tobacco abuse. Her provider has requested a chest CT scan. There is no 
clinical rationale for the requested chest CT scan. There is no documentation of any recent chest x-ray results. 
The review has determined that the requested CT scan is 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 a CT scan of the chest have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a diagnostic computed tomography (CT) scan of the chest.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair seat elevation system (E2300), controller 
connection (E2311), cup holder (K0108), expandable controller upgrade (E2377), harness (E2313), and bag 
hooks (K0108). 
 
You asked the Plan to pre-approve the joystick, cup holder, bag hooks and seat elevation system. You say that 
the items are medically necessary. The Plan denied your request. The Plan says the seat elevation system, bag 
hook, and cup holder are not medical in nature and the joystick 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 joystick, cup holder, bag hooks and 
seat elevation system. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the medical records show the patient having sufficient 
strength to feed themselves and should be able to control the chair. 
 
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 joystick, cup holder, bag hooks and seat elevation system have not been 
met. Therefore, we decided that the Plan does not have to pre-approve the wheelchair seat elevation system 
(E2300), controller connection (E2311), cup holder (K0108), expandable controller upgrade (E2377), harness 
(E2313), and bag hooks (K0108).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869). 
 
You asked the Plan to pre-approve the interspinous spacer placement. You say that the procedure is medically 
necessary. The Plan denied your request. The Plan says 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 the interspinous spacer placement. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the record documents available imaging showing no spinal stenosis at the level 
requested for treatment.  
 
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 interspinous spacer placement have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses. 
 
You asked the Plan to pre-approve eyeglasses. You say that you lost your glasses and can no longer see. You 
say that you are requesting the Plan to provide new glasses. The Plan denied your request. The Plan says your 
vision benefit has been exhausted. 

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $400 annually for eyeglasses. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of glasses have not been met. Specifically, the Plan already paid $400 toward the glasses purchased 
on February 3, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-
approve eyeglasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual adult-size wheelchair (E1161) and accessories. 
 
You asked the Plan to pre-approve a manual adult-size wheelchair and accessories. You say that the requested 
items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 
for durable medical equipment have not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a manual adult-size wheelchair and accessories are being requested for use in a SNF or 
hospital. Therefore, we decided that the Plan does not have to pre-approve a manual adult-size wheelchair 
(E1161) and accessories.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee is a 97-year-old with a 
past medical history of hypertension, chronic kidney disease, congestive heart failure and dementia who 
presented to the acute hospital on October 23, 2021, with delirium/medication refusal and refusal to participate 
with caregivers. While you do require skilled therapy services, there is no documentation that you require 
skilled nursing services. In addition, daily skilled services are not required. In conclusion, you do not require 
the services on an inpatient basis, only in a skilled nursing facility setting.  Services in a long-term care facility 
on a part time basis appear 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the DyAnsys electro-accupuncture device for the 
enrollee. 
 
You asked the Plan to pre-approve the stimulator. You say that this is needed to alleviate pain and increase 
ability to participate in day to day activities. The Plan denied your request. The Plan says this cannot be 
covered with the codes requested. 
 
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is 
not a covered Medicare benefit. 
 
The requested stimulator is not covered by Medicare or the plan. Based on this information, we decided that 
Medicare rules for coverage of the stimulator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the DyAnsys electro-accupuncture device for the enrollee.