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

 
We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the upper right, 
lower right, and lower left quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan 
denied your request. The Plan says the frequency limit has been reached. 
 
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. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have not been met. Specifically, the frequency limit has been reached. The 
record shows that the Plan paid for scaling and root planing for the upper right, lower right quadrants that you 
received on July 8, 2020, and for the lower left quadrant that you received on July 10, 2020, less than 3 years 
ago. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing (D4341) for the 
upper right, lower right, and lower left quadrants.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation 
provided, the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The 
enrollees care needs can be met at a lower level 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 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Spravato 
 
You asked the Plan to pre-approve Spravato. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this drug is not covered under the patient's medical benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Spravato  
 
Benefits for Spravato may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) power standing 
system (E2301), with a stand and drive package (K0108), as well as an expandable controller (E2377) with 
related electronics and hardware (E2311/E2313), to be provided with an approved power wheelchair. 
 
You asked the Plan to pre-approve the requested components/accessories. You say that the requested items 
should be approved. The Plan denied your request. The Plan says the expandable controller is not medically 
necessary, and the other features are statutorily noncovered. 
 
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 components/accessories. 
Our reviewer says that the requested expandable controller and related hardware are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the expandable controller, electronic 
connection and harness do not meet criteria as provided records document that the enrollee has 4/5 upper 
extremity strength and is independent with upper body activities of daily living thus indicating she has 
adequate upper extremity strength and function to operate the wheelchairs power options with their own 
switches. 
 
The rules also specifically state that power seat elevation and power standing features are noncovered. As such, 
the stand and drive feature can also not be covered. 
 
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 components/accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a power seat elevation feature (E2300) power standing system 
(E2301), with a stand and drive package (K0108), as well as an expandable controller (E2377) with related 
electronics and hardware (E2311/E2313), to be provided with an approved power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), bitewing x-rays 
(D0274), crown (D2740), and mesial/distal wedge procedures (D4274) provided on October 6, 2021 by the out 
of network provider. 
You asked the Plan to pay for the dental services. You say that this was an emergency procedure. You say that 
you had an exposed tooth that was decaying from previous botched dental procedures. The Plan denied your 
request. The Plan says dental services received out of network 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, the services you received out of 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation (D0140), bitewing x-rays (D0274), crown (D2740), and mesial/distal wedge 
procedures (D4274) provided on October 6, 2021 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical branch blocks (CPT 64493, 64494). 
 
You asked the Plan to pre-approve medical branch blocks. You say that the medial branch blocks are medically 
necessary. The Plan denied your request. The Plan says the medial branch blocks are not medically necessary 
and do not meet the Medicare LCD coverage criteria. 
 
The Plan follows Medicare rules. 
 
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 medical branch blocks. Our reviewer 
says that medical branch blocks are not medically necessary. Our physician reviewer found the record indicates 
that the enrollee has chronic low back pain. Five levels are requested for bilateral treatment. The provided 
records do not describe unique circumstances that support the medical necessity, as defined by Medicare rules, 
of the requested service. The elements of the coverage rules are not satisfied.  The requested service cannot be 
recommended 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of medical branch blocks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve medical branch blocks (CPT 64493, 64494).
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 IRF care is medically reasonable and necessary. The 
Plan denied your request. The Plan says rules for IRF care have 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 In this case, the complexity of the members nursing, medical and rehabilitation 
needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that 
this individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an inpatient rehabilitation facility. The member continues to have a need for skilled therapy with 
ongoing safety concerns and a potential for functional improvement however, the documentation doesnt 
support that she would meet criteria for admission to an acute inpatient rehabilitation facility. There is no 
indication that the member would require skilled rehabilitation in an IRF, participating in rehab services 15 
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain her 
functional status. The member can receive further services at a lower level 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 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: 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 enrollee needs an IRF admission. The Plan 
denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the 
requirements for approval. 
 
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 that the complexity of the enrollees nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical 
problems are stable. There are no complex nursing or rehabilitation needs. 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 the enrollee 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor and supplies. 
 
You asked the Plan to pre-approve a continuous glucose monitor and supplies. You say that this equipment is 
necessary so you dont have to prick your finger. The Plan denied your request. The Plan says you do not meet 
all of the required Medicare criteria for this equipment. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
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 assess adherence to their CGM regimen and diabetes treatment 
plan. Based in your medical records, you do not meet all of these criteria. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor and supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walker holder. 
 
You asked the Plan to pre-approve a walker holder. You say that a walker holder is medically necessary. The 
Plan denied your request. The Plan says a walker holder is not covered by Medicare. 
 
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 walker holder.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300). 
 
You asked the Plan to pre-approve a power seat elevation feature. You say that you would like this claim 
reprocessed based on medical necessity. The Plan denied your request. The Plan says this item is not covered 
by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. Based on 
this information, we decided that Medicare rules for coverage of a power seat elevation feature have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series x-ray (D0210), panoramic x-ray 
(D0330), and full mouth debridement (D4355) provided on October 12, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says complete series x-ray, panoramic x-ray, and full mouth debridement are not 
covered services. 
 
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 complete series x-ray, 
panoramic x-ray, and full mouth debridement are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for the complete series x-ray (D0210), panoramic x-ray (D0330), 
and full mouth debridement (D4355) provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the endosteal implants (D6010 x 2), guided tissue 
regeneration (D4266), bone replacement grafts (D4263 x 2), periapical x-rays (D0220, D0230), and fluoride 
varnish (D1206) provided from January 26, 2021, to June 10, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should have been covered. The Plan 
denied your request. The Plan says the dental services you received are not listed as 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, the implants, guided tissue 
regeneration, bone replacement grafts, periapical x-rays, and fluoride varnish are not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the endosteal implants (D6010 
x 2), guided tissue regeneration (D4266), bone replacement grafts (D4263 x 2), periapical x-rays (D0220, 
D0230), and fluoride varnish (D1206) provided from January 26, 2021, to June 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the maxillary partial denture - resin base (including, 
retentive/clasping materials, rests, and teeth) (D5211) and mandibular partial denture - cast metal framework 
with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214). 
 
You asked the Plan to pre-approve the upper and lower partial dentures. You say that the dentures are 
medically necessary. The Plan denied your request. The Plan says dentures are not covered under your benefits. 
 
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 the 
maxillary partial denture - resin base (including, retentive/clasping materials, rests, and teeth) (D5211) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) 
and intraoral - periapical each additional radiographic image (D0230) provided November 22, 2021. 
 
You asked the Plan to pay for the intraoral x-rays. You say that you had a routine cleaning and x-rays and 
expected the x-rays to be covered. The Plan denied your request. The Plan says this service is not covered 
under your 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 the intraoral - periapical first radiographic image (D0220) and intraoral - periapical each additional radiographic 
image (D0230) provided November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the filling (D2392) provided on January 12, 2022, by the out 
of network provider. 
 
You asked the Plan to pay for the dental service. You say that you were not aware of the change in your 
coverage. The Plan denied your request. The Plan says dental services received out of network 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 Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage and filling is listed as covered, you pay 
100% for fillings received out of network. Therefore, we decided that the Plan does not have to pay for the 
filling (D2392) provided on January 12, 2022, by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided November 2, 2021. 
 
You asked the Plan to pay for the limited oral exam. You say that you had a dental problem that needed to be 
addressed. The Plan denied your request. The Plan says you have exceeded the frequency limit for this 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. The Plan covers the limited 
oral exam once per plan year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam 
was previously covered on May 12, 2021.  
Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has 
been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - 
problem focused (D0140) provided November 2, 2021.  
 
Your complaint about the Plan having a limit on the number of times this service is covered each year is not a 
valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the 
Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and periapical x-
ray (D0230) provided on December 3, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says the claim processed correctly. 
 
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 and the services are listed as covered, 
the frequency limits have been exceeded. The record shows that comprehensive oral evaluation is covered once 
every 3 years, and periapical x-ray is covered once per calendar year. The record shows that the Plan paid for a 
comprehensive oral evaluation that you received on August 26, 2020. The record also shows that the Plan paid 
for the initial periapical x-ray that you received on the date of service in this case. Therefore, we decided that 
the Plan does not have to pay for the comprehensive oral evaluation (D0150), and periapical x-ray (D0230) 
provided on December 3, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy (97124). 
 
You asked the Plan to pre-approve massage therapy. You say that massage therapy is a covered service and is 
medically necessary. The Plan denied your request. The Plan says massage therapy is not a covered benefit 
under the enrollees 2022 plan. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve massage therapy (97124).