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

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
simple extraction (D7140) provided on June 24, 2021 by a Medicare opt out provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and simple extraction. You say that 
you were not aware that this provider had opted out of Medicare. The Plan denied your request. The Plan says 
you received these services from a provider who chose not to receive Medicare funds. The Plan also says that 
the treating provider opted out of Medicare effective April 1, 2014, to April 1, 2024. 
 
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 
covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the problem focused limited oral evaluation (D0140) and simple extraction 
(D7140) provided on June 24, 2021 by a Medicare opt out provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5212). 
 
You asked the Plan to pre-approve the dental item. You say that you need this denture. 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and partial dentures are listed as 
covered, the frequency limit of once per 60 months has been reached. The record shows that the Plan paid for a 
partial lower denture that you received on November 15, 2021. Therefore, we decided that the Plan does not 
have to pre-approve a partial lower denture (D5212).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three fixed partial denture sectionings (D9120 x3) and 
therapeutic parenteral drug (D9610). 
 
You asked the Plan to pre-approve the fixed partial denture sectionings and therapeutic parenteral drug. The 
Plan denied your request. The Plan says these services are 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. 
 
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 
fixed partial denture sectionings (D9120 x3) and therapeutic parenteral drug (D9610).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) for all four mouth 
quadrants. 
 
You asked the Plan to pre-approve gingival irrigation. You say that these services are medically necessary. 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 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 
gingival irrigation (D4921) for all four mouth quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tooth extraction (D7210) to be provided by an oral 
surgeon. 
 
You asked the Plan to pre-approve a tooth extraction. You say that you visited a general dentist to have the 
tooth extracted but you were told that the dentist could not perform this service and it had to be done by an oral 
surgeon. The Plan denied your request. The Plan says your contract with the plan only provides coverage for 
dental services when they are performed by a participating general dentist. Dental services performed by an 
oral surgeon 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, 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 a 
tooth extraction (D7210) to be provided by an oral surgeon.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endosteal implant (D6010), a custom abutment 
placement (D6057), and an abutment supported crown (D6060), for teeth #13 and #14 to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve an endosteal implant, a custom abutment placement, and an abutment 
supported crown. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan 
says the requested dental services are not covered 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 an endosteal implant (D6010), a custom abutment placement (D6057), and an abutment supported crown (D6060), 
for teeth #13 and #14 to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower 
denture (D5212). 
 
You asked the Plan to pre-approve dentures. You say that your current dentures are causing issues and you 
would like to have new ones made. The Plan denied your request. The Plan says you previously received a 
complete upper denture (D5110) and lower partial denture (D5212) in January of 2019, which were covered by 
the Plan at that time. These services are only covered once every five years. 
 
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 can cover one 
complete upper denture every five plan years and one lower partial denture with a resin base every five plan 
years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a 
frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a complete upper denture (D5110) and a partial lower denture (D5212).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional mileage for routine transportation. 
 
You asked the Plan to provide additional mileage. You say that this benefit is unfair based on the area where 
the enrollee lives, as the closest specialists are more than 30 miles away. The Plan denied your request. The 
Plan says the routine transportation benefit offers one-way trips with a mileage limit of 30 miles per trip. As the 
transportation requested in this case exceeds 30 miles, this is not a covered benefit, and this request is denied. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 12 routine transportation trips each year. Trips must originate in certain counties and 
must not exceed 30 miles per trip.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to provide additional mileage for routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided you appear to not be stable enough for transfer 
at this time. Acute care services can be safely administered at the current facility for the time being until 
treatment is completed and transfer to a lower level of care is more appropriate. You do not require services at 
the LTACH that are not already available at the current facility. There are no services at the LTACH that you 
require that are not already available and covered at the current facility. 
 
   
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency ambulance transportation. 
 
You asked the Plan to pre-approve non-emergency ambulance transportation. You say that the requested 
service is medically necessary. The Plan denied your request. The Plan says the service at issue is not 
medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same 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 non-emergency ambulance 
transportation. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
record does not indicate that the enrollee's clinical condition is such that other methods of transportation, such 
as stretcher van, are contraindicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergency ambulance transportation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve non-emergency ambulance transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 1 power wheelchair (PWC) (K0813), and 
battery E2365). 
 
You asked the Plan to pre-approve a PWC and battery. You say that the item is medically necessary. The Plan 
denied your request. The Plan says no documentation of home assessment was provided. 
 
The Plan must follow Medicare rules. Medicare rules say that the beneficiarys home must provide adequate 
access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is 
provided. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a PWC and battery have not been met. Therefore, we decided that the Plan does not have to pre-
approve a group 1 power wheelchair (PWC) (K0813), and battery E2365).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant removal procedure. 
 
You asked the Plan to pre-approve the implant removal procedure. You say that this procedure is medically 
necessary. The Plan denied your request. The Plan says insufficient information was provided to support the 
procedure. 
 
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 an implant removal procedure. have 
been met. No clinical records were provided from the physician to support these services. Therefore, we 
decided that the Plan does not have to pre-approve an implant removal procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve grocery deliveries. 
 
You asked the Plan to pre-approve grocery deliveries. You say that you were eligible for this benefit in the 
past. The Plan denied your request. The Plan says you must have both high blood sugar (diabetes) and a 
condition that affects how you feel (depression). 
 
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for 
enrollees with eligible conditions.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of grocery deliveries have not been met. Specifically, we have confirmed that you do not have 
diabetes, which is a required diagnosis to receive the grocery benefit. Therefore, we decided that the Plan does 
not have to pre-approve grocery deliveries.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided the enrollee only requires short-term additional 
acute care services that can safely be administered at the current facility. The enrollee does not require services 
at the LTACH that are not already available at the current facility. There are no services at the LTACH that the 
enrollee requires that are not already available and covered at the current facility. 
  
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 11, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this procedure is not separately reportable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare rules say that specimen validity testing is not covered separately. The services at issue in this case are for the purpose of specimen validity testing. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement power wheelchair and accessories. 
 
You asked the Plan to pre-approve the replacement power wheelchair. You say that the replacement chair is 
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical 
equipment is determined through program instructions. In the absence of program instructions, A/B MACS (B) 
may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years. 
 
We looked at the file and Medicare rules. The record shows the enrollee's current chair was approved in July 
2018. This chair is less than 5 years old. A replacement is non-covered. Since the chair is non-covered, the 
accessories are also non-covered. Based on this information, we decided that Medicare rules for coverage of 
the replacement power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-
approve a replacement power wheelchair and accessories.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 Prolia. Our reviewer says that the 
requested drug is medically reasonable and necessary for the enrollee's condition. Our physician reviewer 
found the record indicates that the enrollee has a diagnosis of osteoporosis at high risk of fracture and breast 
cancer on an aromatase inhibitor. The Food and Drug Administration has stated that the requested drug is 
indicated for the enrollee's condition. The elements of the coverage criteria are satisfied. The requested service 
is 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 Prolia have been met. Therefore, we decided that the Plan has to pre-approve 
Prolia.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) scan, provided on December 
18, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the CT scan. You say that the service was medically necessary. The Plan denied 
your request. The Plan says this service was provided in an out-of-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 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 computed tomography (CT) scan, provided on 
December 18, 2020 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on November 20, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that bystanders 
called the ambulance after she had fallen in a parking lot. You also say that there was no examination, just 
questions asked to ensure you were alright. The Plan denied your request. The Plan says ambulance service is a 
transport benefit, and it is only payable when you are transported to a hospital. If an ambulance is called and 
you receive care, but decide not to be transported to a hospital, those services are not covered. The Plan also 
says that you declined transportation. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 20, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on November 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically 
necessary. The Plan denied your request. The Plan says there is no clinical documentation to support that the 
member has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a 
standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a 
four-week trial. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652, E0667).