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

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all four quadrants. 
 
You asked the Plan to pre-approve gingival irrigation. You say that this service is necessary and goes along 
with your other treatment. The Plan denied your request. The Plan says this service is 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 
gingival irrigation (D4921) for all four quadrants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair accessory, harness for upgrade to 
expandable controller, including all fasteners, connectors and mounting hardware (E2313) power wheelchair 
accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at 
initial issue (E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that the enrollee has a diagnosis of post-
polio syndrome. The diagnosis alone qualifies her for a group 3 power wheelchair based on Medicare 
guidelines. The Plan denied your request. The Plan says the upgraded electronics 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 the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested items exceed the enrollee's medical need. The enrollee has tilt, recline 
and power elevating leg rest power options of on the approved wheelchair but the enrollee's upper extremity 
function supports that the patient can control any power options through their own switches. 
 
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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve power wheelchair accessory, harness for upgrade to expandable controller, 
including all fasteners, connectors and mounting hardware (E2313) power wheelchair accessory, expandable 
controller, including all related electronics and mounting hardware, upgrade provided at initial issue (E2377).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D1110), and a periodic oral 
evaluation (D0120) provided by an out-of-network provider on January 12, 2022. 
 
You asked the Plan to pay for a periodic oral evaluation and a periodic oral evaluation. You say that you did 
not realize you did not have out-of-network benefits. The Plan denied your request. The Plan says services 
provided by an out-of-network provider are not covered benefits. 
 
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. The Plan covers a periodic 
oral evaluation and a periodic oral evaluation when the services are provided by participating provider.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a periodic oral evaluation and a periodic oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D1110), and a periodic oral evaluation 
(D0120) provided by an out-of-network provider on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power seat elevation system (E2300). 
 
You asked the Plan to pre-approve power seat elevation system. You say that you are requesting review of 
medical necessity of this power wheelchair with tilt and power elevating leg rests for her current medical 
needs. The Plan denied your request. The Plan says this item does is not primarily medical in nature 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.   
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of power seat elevation system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the extraction (D7210). 
 
You asked the Plan to pre-approve the extraction. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
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. Specifically, records indicate the request is for a periodontist and not a 
general dentist. Therefore, we decided that the Plan does not have to pre-approve the extraction (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three surgical placements of implant bodies: endosteal 
implants (D6010 x3), three custom fabricated abutments (D6057 x3), and three abutment supported porcelain 
fused to metal crowns (D6059 x3). 
 
You asked the Plan to pre-approve the endosteal implants, custom fabricated abutments, and abutment 
supported porcelain fused to metal crowns. You say that you would like to appeal these services because you 
do not have any teeth. 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 three 
surgical placements of implant bodies: endosteal implants (D6010 x3), three custom fabricated abutments 
(D6057 x3), and three abutment supported porcelain fused to metal crowns (D6059 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adult 
dentition (D8090). 
 
You asked the Plan to pre-approve the dental service. You say that you need this service to prevent your teeth 
from moving and avoid pain. The Plan denied your request. The Plan says comprehensive orthodontic 
treatment of the adult dentition is not a covered service. 
 
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 comprehensive 
orthodontic treatment of the adult dentition is not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve comprehensive orthodontic treatment of the adult dentition 
(D8090).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental anesthesia with surgical extractions. 
 
You asked the Plan to pre-approve the dental services. You say that it is medically necessary for these services 
to be performed in a hospital setting under general anesthesia. The Plan denied your request. The Plan says this 
service is not covered by the enrollee's dental benefit or by Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
dental anesthesia with surgical extractions.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computer-assisted surgical navigation (MAKOplasty). 
 
You asked the Plan to pre-approve computer-assisted surgical navigation (MAKOplasty). You say that the 
requested computer-assisted surgical navigation (MAKOplasty) is medically necessary. The Plan denied your 
request. The Plan says the requested computer-assisted surgical navigation (MAKOplasty) 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 computer-assisted surgical navigation 
(MAKOplasty). Our reviewer says that the requested computer-assisted surgical navigation (MAKOplasty) is 
not medically necessary. Our physician reviewer found there is limited published, large-scale, long-term peer-
reviewed literature that shows this request to be an effective and/or safe treatment for the noted pathology. There are no large volume, high-quality clinical trials that confirm the clinical benefits (ultimate outcomes of 
functionally improvement and pain reduction) of computer-assisted surgery over standard surgical approaches 
in total hip arthroplasty. There is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested computer-assisted 
surgical navigation (MAKOplasty) for the approved hip surgery with inpatient admission, in this case, 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 computer-assisted surgical navigation (MAKOplasty) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve computer-assisted surgical navigation 
(MAKOplasty).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve blepharoplasty to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve blepharoplasty. You say that you are requesting for reconsideration so see 
an Out-of-network (OON) provider. The Plan denied your request. The Plan says no medical need is shown as 
to why you cannot get this service with an in-network provider. 
 
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 
blepharoplasty to be provided by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
June 13, 2021. 
 
You asked the Plan to waive the copayment for an ER visit. You say that you did not go to the emergency room 
on June 13, 2021. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for an in-network emergency room visit.  
 
The medical record shows you had an emergency room visit on June 13, 2021. You have been asked to pay a 
$90 copayment for an ER visit ($51.99 copayment + $38.01 copayment = $90). An ER visit falls within the Emergency Care benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room 
(ER) visit provided on June 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost-sharing for a pulmonary stress test (94618) provided 
on December 21, 2021. 
 
You asked the Plan to waive the cost-sharing for the stress test. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). The enrollees contract with the Plan clearly says that enrollees 
must pay a $35 copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 
  The enrollee has been asked to pay a $33.32 copayment for a stress test. Stress tests fall within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that the enrollee has been 
asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the cost-sharing for a pulmonary stress test (94618) provided on December 21, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continuation of SNF services provided from October 8, 2021, 
through October 19, 2021 and from October 28, 2021, through November 6, 2021. 
 
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says no 
daily skilled needs were identified. 
 
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 pay for continuation of SNF service provided from 
October 8, 2021, through October 19, 2021 and from October 28, 2021, through November 6, 2021. Our 
reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the 
enrollee did not require any skilled nursing or rehabilitation services on a daily basis. The enrollee was not expected to 
make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent 
deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish 
a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled 
services on an inpatient basis, at a SNF level of care. The enrollee did not have any parental medications, 
complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved and 
was medically stable. The enrollee's function was at or near her prior level of function and she could be 
discharged to a lower level of care for further services. The enrollee required custodial services.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of SNF service provided from October 8, 2021, through  
October 19, 2021 and from October 28, 2021, through November 6, 2021 have not been met. Therefore, we 
decided that the Plan does not have to pay for continuation of SNF services provided from October 8, 2021, 
through October 19, 2021 and from October 28, 2021, through November 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 9, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says an edit exists between the two codes. 
 
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 imaging services provided to the enrollee on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a podiatry visit provided on September 3, 
2021. 
 
You asked the Plan to waive the copayment for the podiatry visit. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for Physician/Practitioner services, including doctors office visits.  
 
 You have been asked to pay a $40 copayment for a podiatry visit. Podiatry visits fall within the 
Physician/Practitioner services, including doctors office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a podiatry visit provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that it was not possible to get prior authorization for the 
services due to staff shortages. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advance. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in 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 for the office visit provided on October 22, 2021 by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve alignable system (L5910), protective outer surface 
covering system (L5962), and socket insert (L5655). 
 
You asked the Plan to pre-approve the requested equipment. You say that this equipment is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that protective outer surface covering systems 
(L5962, L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are 
used by a beneficiary who has special needs for protection against unusually harsh environmental situations 
where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by 
L5704, L5705, L5706, and L5707. Medicare rules say that no more than two of the same socket inserts (L5654, 
L5655, L5656, L5658, L5661, L5665, L5673, L5679, L5681, L5683) are allowed per individual prosthesis at 
the same time. Medicare rules say that Medicare considers equipment to be reasonable and necessary if the 
equipment does not serve the same purpose as other equipment already available to an enrollee. 
 
We looked at the file and Medicare rules. In this case, the documentation does not indicate that the enrollee has 
special needs for protection against unusually harsh environmental situations. In addition, two of the same 
socket inserts have already been approved. Finally, there is no evidence the enrollees current alignable system 
would not be sufficient for the enrollees needs. Based on this information, we decided that Medicare rules for 
coverage of the requested equipment have not been met. Therefore, we decided that the Plan does not have to 
pre-approve alignable system (L5910), protective outer surface covering system (L5962), and socket insert 
(L5655).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron. 
 
You asked the Plan to pre-approve Palonosetron. The Plan denied your request. The Plan says the drug regimen 
is a low emetogenic risk. 
 
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 Palonosetron. Our physician reviewer 
found that the record indicates the enrollee is scheduled to receive low emetogenic potential chemotherapy with 
gemcitabine, paclitaxel-protein bound (Abraxane), and dexamethasone. The FDA has not stated that the 
requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Palonosetron have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Palonosetron.