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

 
We decided that the Plan has to pre-approve a joystick, expandable controller, harness, and electronic 
connection device for a power wheelchair. 
 
You asked the Plan to pre-approve joystick, expandable controller, harness, and electronic connection device. 
You say that the enrollee needs this wheelchair for mobility. The Plan denied your request. The Plan says that 
these components are not medically necessity. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit supporting medical records to us for review. We 
requested this information, but it was not submitted to us. Without this information, we cannot determine 
whether these power wheelchair components are medically reasonable and necessary for you. Therefore, the 
Plan has not shown that its decision to deny authorization for these components is correct or justified. 
Therefore, we decided that the Plan has to pre-approve a joystick, expandable controller, harness, and 
electronic connection device for a power wheelchair.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation with limited field 
of view - less than one whole jaw (D0364) provided on December 12, 2022. 
 
You asked the Plan to pay for code D0364. You say that the x-ray was inconclusive, and a cone beam CT 
capture scan of the infected area was performed. The Plan denied your request. The Plan says this service is not 
covered under the 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 pay for cone 
beam CT capture and interpretation with limited field of view - less than one whole jaw (D0364) provided on 
December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - complete series of radiographic images (D0210) 
provided on November 28, 2022. 
 
You asked the Plan to pay for dental services. You say that your insurance should cover the services you 
received because the provider is in-network. The Plan denied your request. The Plan says this service is not 
covered under your Plan. 
 
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. Intraoral - complete series of 
radiographic images (D0210) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0210 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral - 
complete series of radiographic images (D0210) provided on November 28, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
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 skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the facet joint injections (64493, 64494, and 64495). 
 You asked the Plan to pre-approve the facet joint injections. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint nerve blocks are covered when 
all criteria listed in Medicare Rules section is met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the facet joint injections. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found there is no documentation as to 
why the enrollee is not a candidate for a radiofrequency ablation. In addition, there is no documentation of the 
degree of pain relief received with prior injections. 
 
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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the facet joint injections (64493, 64494, and 64495).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care visit provided on 
December 6, 2022. 
 
You asked the Plan to waive the copayment for the primary care visit. You say that you think that this visit 
should be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $10 
copayment for each covered visit or consultation in an outpatient location with your primary care provider or 
other primary care provider. 
 
You have been asked to pay a $10 copayment for the primary care visit. This item/service falls within the 
physician/practitioner services, including doctor's 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 the primary care visit provided on December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and core buildup services (D2950, D2740) provided 
on February 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 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 crown 
and core buildup services (D2950, D2740) provided on February 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0220) and 
pontic - porcelain/ceramic (D6245) provided on October 16, 2022, to November 16, 2022. 
 
You asked the Plan to pay for the dental services. You say that you pay for insurance coverage, and you expect 
your dental work to be covered. The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. 
 
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. This benefit includes the  
requested intraoral - periapical first radiographic image (D0220) but is limited to one procedure code per 
calendar year. This benefit includes only those items and services specifically listed in your Plan contract. 
pontic - porcelain/ceramic (D6245) is not  covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received a covered D0220 on November 8, 2022; therefore, your benefit was exhausted. D6245 is 
not covered under your dental benefits. Therefore, we decided that the Plan does not have to pay for intraoral - 
periapical first radiographic image (D0220) and pontic - porcelain/ceramic (D6245) provided on October 16, 
2022, to November 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orthofix Trinity Elite Allograft (20930). 
 
You asked the Plan to pre-approve Orthofix Trinity Elite Allograft (20930). You say that the requested 
Orthofix Trinity Elite Allograft (20930) is medically necessary. The Plan denied your request. The Plan says 
the requested Orthofix Trinity Elite Allograft (20930) 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 Orthofix Trinity Elite Allograft 
(20930). Our reviewer says that the requested Orthofix Trinity Elite Allograft (20930) is not medically necessary. Our physician reviewer found the enrollee was being treated for spinal stenosis of the lumbar region 
with neurogenic claudication. She presented with lower back pain with radiation. The symptoms are worse. 
There is continued pain in the lower back with radiation to the left leg and foot. The pain is rated 9/10 and is 
aching, stabbing, and tingling. The exam reveals an antalgic gait.  
 
However, there is limited published, large-scale, long-term peer-reviewed literature that shows this requested 
allograft to be an effective and/or safe treatment for the noted pathology. Further studies are needed to 
demonstrate this request has beneficial outcomes compared with conventional treatment. There is no 
compelling rationale presented or extenuating circumstances noted to support the medical necessity of this 
request as an exception. Therefore, the requested Orthofix Trinity Elite Allograft (CPT 20930), 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 Orthofix Trinity Elite Allograft (20930) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Orthofix Trinity Elite Allograft (20930).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periapical each additional radiographic image (D0230) 
provided on December 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that when you made your appointment with the 
dental office you were told they were in-network. You also say that you are requesting a reconsideration.  The Plan denied your request. The Plan says your benefit for the periapical each additional radiographic image 
was exhausted when the claim was sent for reprocessing. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service December 12, 2022. 
Therefore, we decided that the Plan does not have to pay for a periapical each additional radiographic image 
(D0230) provided on December 12, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy provided on December 08, 2022.

You asked the Plan to pay for psychotherapy. You say that you are requesting reconsideration. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered.

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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for psychotherapy provided on December 08, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD.  
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 portable ventilator. Our reviewer says 
that the member does not need this item. Our physician reviewer found a diagnosis of COPD is mentioned 
occasionally in the record, but there is no documentation of this with pulmonary function tests. Spirometry is 
described as showing severe restriction. There is no diagnosis of thoracic restrictive disease or neuromuscular 
disease. The patient has severe obesity and presumed obesity hypoventilation syndrome (OHS). An arterial 
blood gas (ABG) when acutely ill was consistent with acute hypercarbic respiratory failure. There is no 
documentation of chronic hypercarbic respiratory failure with an ABG done while stable. This patient may 
benefit from BiPAP during sleep as an outpatient. If there is severe COPD, the average volume-assured 
pressure support (AVAPS) mode can be provided via BiPAP. Medicare does not cover a home ventilator for 
the treatment of OHS, or when used at settings that can be provided with BiPAP. 
 
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 portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate services during lumbar fusion 
surgery. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
clinical effectiveness has not been demonstrated. 
 
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 requested services. Our physician 
reviewer found that bone marrow aspirate services are considered experimental in the setting of spine surgery. 
More research is needed to show its efficacy. Therefore, the request is not 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate services during lumbar fusion surgery.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor-controlled ankle foot system (L5973). 
 
You asked the Plan to pre-approve a microprocessor-controlled ankle foot system. You say that the enrollee 
requires new prosthesis due to ill fit and old and worn out. The Plan denied your request. The Plan says that 
notes do not show why a mechanical foot will not meet the enrollee's needs. 
 
The Plan follows Medicare rules. Medicare rules say the requested item is covered when the enrollee has a 
function level of 3 or above and device is medically 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 a microprocessor-controlled ankle foot 
system. Our reviewer says that need this medical item. Our physician reviewer found that the enrollee is noted 
to be a K3 level ambulator and can walk on uneven terrain and works as a landscaper. A prosthetic evaluation 
dated February 10, 2023, indicated that the enrollee has the potential to be a K3 level ambulator. The enrollee 
required revision of his residual limb due to skin breakdown from the prosthetic socket. The prosthetic socket 
and components required replacement. The enrollee requires a transtibial prosthesis for mobility and 
accomplishing daily activities. The clinical documentation from the enrollees physician and prosthetic 
evaluation indicate that the enrollee has the ability to be a K3 level ambulator. Therefore, the requested 
microprocessor-controlled ankle foot system (L5973) is 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 a microprocessor-controlled ankle foot system have been met. Therefore, we 
decided that the Plan has to pre-approve a microprocessor-controlled ankle foot system (L5973).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate during lumbar fusion surgery. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says studies 
have not proven that this procedure is helpful for the treatment of the enrollee's problem. 
 
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 requested services. Our physician 
reviewer found that bone marrow aspirate is experimental. More research is needed. Therefore, the request 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate during lumbar fusion surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says based on the 
information submitted, there is no documentation that you meet all three criteria. 
 
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 SSBCI benefits have been met. 
Medical records were not provided for this case. The record shows that the Plan made multiple attempts to 
obtain this information, but it was not received. Without medical records we are unable to determine if you 
meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says based on the 
information submitted, there is no documentation that you meet the criteria. 
 
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 SSBCI benefits have been met. 
Medical records were not provided with this case. The record shows that the Plan attempted to obtain this 
information, but it was not received. Without medical records we are unable to determine if you meet the 
criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special supplemental 
benefits for the chronically ill (SSBCI).