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

 
We decided that the Plan does not have to pre-approve 10 additional one-way trips. 
 
You asked the Plan to pre-approve 10 additional one-way trips. You say that you were informed that you had 
unlimited trips. The Plan denied your request. The Plan says your plan covers 10 one-way trips every year. The 
Plan also says that you have utilized all 10 trips. 
 
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 a maximum of 10 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve 10 additional one-way trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair with single power 
option and accessories. 
 
You asked the Plan to pre-approve a group three power wheelchair with single power option and accessories. 
You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the enrollee does 
not meet criteria for the requested items. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchairs with power options are only 
covered for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the enrollee is not considered high risk 
for skin breakdown. The documentation shows that the enrollee has no current or prior history of pressure 
ulcers. The enrollee has no self-catheterization or spasticity. The enrollee does not use a ventilator mounted to 
the power wheelchair. The requested power tilt and power reclines exceed the enrollees needs. This means the 
requested power wheelchair with power option exceeds the enrollees medical needs at this time. 
Based on this information, we decided that Medicare rules for coverage of a group three power wheelchair with 
single power option and accessories have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a group three power wheelchair with single power option and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group three power wheelchair with multiple power 
options (K0862) and accessories. 
 
You asked the Plan to pre-approve a group three power wheelchair with multiple power options and 
accessories. You say that the item is medically necessary. The Plan denied your request. The Plan says the 
member does not have a medical diagnosis of neurological disease, myopathy or congenital skeletal deformity 
causing mobility limitation for which a Group 3 power wheelchair base would be medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a Group 3 PWC with Multiple Power Options 
(K0861, K0862, K0863, K0864) is covered if the beneficiary's mobility limitation is due to a neurological 
condition, myopathy, or congenital skeletal deformity. If the PWC base is not covered, then related accessories 
will be denied. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a group three power wheelchair with multiple power options and accessories have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a group three power wheelchair with multiple 
power options (K0862) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical collar provided on May 31, 2022. 
 
You asked the Plan to pay for the billed services. You say that the documentation supports the services. The 
Plan denied your request. The Plan says a valid physician order was not submitted. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain 
the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the 
cervical collar provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D2955, D3331, D2390)  provided in Mexico 
from December 7, 2021, to December 24, 2021. 
 
You asked the Plan to pay for dental services. You say that these services were provided in an emergency. The 
Plan denied your request. The Plan says dental services outside of the United States 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 when received outside of the United States. Therefore, we decided that 
the Plan does not have to pay for dental services (D2955, D3331, D2390)  provided in Mexico from December 
7, 2021, to December 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the orally administered enteral formula. 
 
You asked the Plan to pre-approve the orally administered enteral formula. You say that this is necessary for 
the enrollee's condition. The Plan denied your request. The Plan says this enteral formula is not covered by 
Medicare or the Plan when administered orally. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve the orally administered enteral formula.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar laminectomy at an additional level.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis and spondylolisthesis. The exam reveals subtle weakness in the lower extremities particularly with hip flexion. Detailed documentation is not evident regarding the need for an additional level for the already approved surgery from L2-L5. The magnetic resonance imaging (MRI) did not demonstrate significant pathology at the adjacent levels. There are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested procedure 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar laminectomy at an additional level.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Nuvasive Osteocel Allograft represented by code 
20930. 
 
You asked the Plan to pre-approve Nuvasive Osteocel Allograft. You say that the records provided support the 
need for the services which remain in dispute. The Plan denied your request. The Plan says that medical 
necessity for the denied service has not been established after clinical review and per the peer-reviewed 
medical literature. 
 
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 Nuvasive Osteocel Allograft. Our reviewer says that Nuvasive Osteocel Allograft is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the record indicates that the enrollee has cervical spondylosis with 
myelopathy. There is insufficient literature to support the safety and efficacy of the requested product 
compared to standard products that are available. The record provided does not establish the medical necessity 
and reasonableness, as defined by Medicare rules, of the requested service. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Nuvasive Osteocel Allograft have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Nuvasive Osteocel Allograft represented by code 20930.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #29 provided on July 8, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you would like the plan to pay for the dental 
service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
the core buildup is not covered by the 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 pay for the core 
buildup (D2950) for tooth #29 provided on July 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on June 8, 2022. 
 
You asked the Plan to pay for the services provided. You say that an NOA was submitted. The Plan denied 
your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. The admission date on the notice of admission is inconsistent with the 
admission date on the final claim. Based on this information, we decided that Medicare rules for coverage of 
the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the home 
health services provided on June 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 March 21, 2021. 
Therefore, we decided that the Plan does not have to pay for the dental services on June 29, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the lab testing services provided on January 20, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says that the claim 
did not contain a DEX Z-Code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.  
 
The file shows that the enrollee received an AlloMap test, billed with CPT code 81595. We find that CPT code 
81595 was billed with DEX Z-Code ZB863. According to the Local Coverage Article, A58481, Response to 
Comments for the AlloSure or Equivalent Cell-Free DNA Testing for Kidney and Heart Allografts, the 
AlloMap testing is billed with a CPT code 81595 and Z-Code ZB863. Based on this information, we decided 
that Medicare rules for coverage of the testing services have been met. Therefore, we decided that the Plan has 
to pay for the lab testing services provided on January 20, 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 pre-approve a complete maxillary denture (D5110) and a partial 
mandibular denture (D5214) provided by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that this provider never provided the dentures 
to you. 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 April 7, 2022. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a partial 
mandibular denture (D5214) provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for audiology services provided on April 4, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for audiology services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
  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 audiology services provided on April 4, 2022, 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 immediate denture (D5130) provided on August 10, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the dental visit was for an emergency and the 
service provided was necessary. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the immediate dentures are not covered by the 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 pay for the 
immediate denture (D5130) provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture - flexible base (including 
retentive/clasping materials, rests, and teeth) (D5226). 
 
You asked the Plan to pre-approve the mandibular partial denture - flexible base (including retentive/clasping 
materials, rests, and teeth) (D5226). 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 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 
mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) (D5226).
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 LTACH care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the care needed in the current acute care facility.

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 the enrollee was admitted with septic shock in the setting of necrotizing fasciitis.  The record indicates that the enrollee has a poor prognosis for recovery and continues to have ongoing acute medical issues that require acute care services.  The enrollee continues to receive acute care services, and these have not been denied.  The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 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: 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 June 27, 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 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 January 19, 2021. 
Therefore, we decided that the Plan does not have to pay for a crown and core buildup services (D2950, 
D2740) provided on June 27, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the crowns - resin-based composite (indirect) (D2710) provided on July 
11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel this service should be covered. The 
Plan denied your request. The Plan says that your benefit for the requested item or service has already been 
exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for the crowns - resin-based composite (indirect) 
(D2710) provided on July 11, 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 a comprehensive oral evaluation (D0150) and an occlusal 
adjustment (D9951). 
 
You asked the Plan to pay for the dental services. You say that you were very clear with the provider that you 
needed a cleaning only. You also say that the provided said the comprehensive oral evaluation (D0150) was 
needed since you were a new patient. You also say you do not understand why the Plan will not approve your 
tooth grinding charge. The Plan denied your request. The Plan says a comprehensive oral evaluation (D0150) 
has already been exhausted. The Plan also says that an occlusal adjustment (D9951) is not covered under your 
contract under any normal circumstances. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan rules say that a 
comprehensive oral evaluation (D0150) is only covered once every three plan years. The plan rules also say 
that any services not listed in the EOC pages 4-81 to 4-90 are not covered. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for a comprehensive oral evaluation (D0150) was exhausted on date of service October 14, 
2021. The record also shows that occlusal adjustments (D9951) are excluded from the benefit. Therefore, we 
decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an occlusal 
adjustment (D9951).