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

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies (A4239, A4238). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
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. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM) and 
supplies (A4239, A4238).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be covered. This means that the 
enrollee will have to pay the provider in full for the services furnished. 
 
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 
physical therapy 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 pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says members may obtain services from an out-of-network provider only when 
providers of specialized services are not available in-network (i.e., a unique sub-specialty where the plan does 
not have a contracted provider), or in urgent and/or emergent situations. To obtain authorization for a provider 
of specialized services that are not available in-network, the enrollees primary care physician (PCP) will submit 
a referral request and any supporting documentation to the enrollees assigned IPA/medical group. For any 
urgent or emergent services, the care may be provided first, and then a claim for those services submitted to the 
plan by the provider along with supporting medical documentation. 
 
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 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a shower chair. 
 
You asked the Plan to pay for a shower chair. You say that this is medically necessary for you. 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 shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pay for a shower chair.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CT scan of the heart. 
 
You asked the Plan to pre-approve a CT scan of the heart. You say that the test will be used to further diagnose 
and make and accurate and best determination to manage the enrollee's medical care. The Plan denied your 
request. The Plan says a CT scan of the heart 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 CT scan of the heart. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no significant benefit of the CT imaging off the heart with a quantitative 
evaluation of coronary calcium in guiding optimal management of the enrollee. A CT imaging of the heart 
without contrast material with quantitative evaluation of the coronary calcium is considered experimental or 
investigational for the evaluation and management of the enrollee's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CT scan of the heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you need permanent dentures so you can 
properly eat. The Plan denied your request. The Plan says your benefit for the requested items or services 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on the date of service of January 3, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a 
complete lower denture (D5120).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spinal canal 
and contents. 
 
You asked the Plan to pre-approve the MRI.. You say that the services are medically necessary. 
 The Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lumbar spinal canal and 
contents. Our reviewer says that the MRI is medically necessary. Our physician reviewer found the enrollee is 
noted to have a history of lower extremity neuropathy and superimposed low back pain with radicular features. 
An electromyography (EMG) demonstrated that the enrollee has bilateral lumbar radiculopathy. The requested 
imaging study would be appropriate for further evaluation of the enrollee's complaints and symptoms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spinal canal and contents. have been met. Therefore, we 
decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spinal canal and 
contents.  
 
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: Favorable

 
We decided that the Plan has to pay for the durable medical equipment provided on May 25, 2022. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not 
covered. 
 
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 rules state that DMEPOS is covered only when there are both a physician order and proof of 
delivery.  
 
We looked at the file and the rules. Medicare does cover electrical stimulation as a benefit. The medical records 
show that electrical stimulation is part of the enrollees treatment plan. The Plan has not provided Medicare 
ruling or any other rationale to show that the services are experimental in nature. The Plan has not made 
reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your 
request. Therefore, we decided that the Plan has to pay for the durable medical equipment provided on May 25, 
2022.  
 
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 bone replacement graft for ridge preservation - per site 
(D7953) provided on November 2, 2022. 
 
You asked the Plan to pay for dental services. You say that the services are necessary as part of your treatment 
plan. 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. Bone replacement graft for 
ridge preservation - per site (D7953) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7953 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for bone replacement 
graft for ridge preservation - per site (D7953) provided on November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) 
 
You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM because it 
should be covered. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
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. 
 
  We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor 
(CGM)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
#31. 
 
You asked the Plan to pre-approve the dental services. You say that you never received a permanent crown, 
and you are dissatisfied about the denial. The Plan denied your request. The Plan says your benefit for the 
requested items or services 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. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested items or services was exhausted on the date of service of September 9, 
2019. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and core buildup 
(D2950) for tooth #31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you need this item for daily living. The 
Plan denied your request. The Plan says you can get the same items from an in-network 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 
a power wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on November 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was a dental emergency, and your regular 
dentist was not available. The Plan denied your request. The Plan says emergency services require the enrollee 
to reach out to dental group prior to obtaining 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 items or services are not 
covered under this benefit without prior authorization or a reasonable attempt to contact the Plan before 
services are rendered. Therefore, we decided that the Plan does not have to pay for the consultation (D9310) 
provided on November 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as you do not meet the clinical 
requirements to be approved. 
 
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. 
 
   We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bronchoscopy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a bronchoscopy. You say that this is medically necessary and should be 
covered. The Plan denied your request. The Plan says this facility is an out-of-network facility. This procedure 
needs to be done in an in-network 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 
a bronchoscopy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Limited Oral Evaluation - Problem Focused (D0140) 
provided on October 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that this should 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. 
 
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 August 15, 2022. 
Therefore, we decided that the Plan does not have to pay for Limited Oral Evaluation - Problem Focused 
(D0140) provided on October 24, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient mental health to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve outpatient mental health. You say that you are requesting reconsideration. 
The Plan denied your request. The Plan says the enrollee must get their care from network providers that are 
affiliated with their primary care physician's (PCPs) medical group. Usually, the plan wont cover care from a 
provider who doesnt work with the health plan and the enrollees PCPs medical group. This means that the 
enrollee will have to pay the provider in full for the services furnished from providers outside of the network. 
 
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 
outpatient mental health 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 pre-approve a chiropractor visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a chiropractor visit. You say that you called the offices and confirmed that 
this was in-network. The Plan denied your request. The Plan says there was no preauthorization by a primary 
care provider (this is different than a referral) for an out-of-network (OON) provider or facility, and this was 
not an emergency. 
 
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 
a chiropractor visit to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three surgical extractions, two removal of impacted 
tooth, general anesthesia first 15 minutes and three units of general anesthesia each subsequent 15-minute 
increment. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are not covered by the Plan's 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 pre-approve three 
surgical extractions, two removal of impacted tooth, general anesthesia first 15 minutes and three units of 
general anesthesia each subsequent 15-minute increment.