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

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213), and a mandibular 
partial denture (D5214) to be provided by a participating provider. 
 
You asked the Plan to pre-approve a maxillary partial denture and a mandibular partial denture. You say that 
you would like approval for these services. The Plan denied your request. The Plan says D5213 and D5214 are 
provided 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 Plans coverage rules apply in this case. The Plan covers a maxillary 
partial denture and a mandibular partial denture when the services are medically necessary and reasonable.  
 
We looked at this physician's review, the file, and Medicare rules. D5213 and D5214 was previously provided 
on January 27, 2022. Based on this information, we decided that the Plan's rules for coverage of a maxillary 
partial denture and a mandibular partial denture have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a maxillary partial denture (D5213), and a mandibular partial denture (D5214) 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 custom fabricated abutment (D6057), and abutment 
supported porcelain crown (D6059) provided by a participating provider. 
 
You asked the Plan to pre-approve a custom fabricated abutment and abutment supported porcelain crown. You 
say that the enrollee cannot afford the implant crown if the Plan denies paying. The Plan denied your request. 
The Plan says the requested dental services 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 
custom fabricated abutment (D6057), and abutment supported porcelain crown (D6059) provided by a 
participating provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable loop recorder (ILR). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this device is not a standard of care. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke or 
any other apparent indication for an implantable loop recorder. In summary, there is insufficient documentation 
to support the medical necessity for insertion of an ILR in your clinical management. 
 
 
 
 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an implantable loop recorder (ILR).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Tempus Gene Panel (81206, 81292) provided on August 5, 2021. 
You asked the Plan to pay for a Tempus Gene Panel. You say that this should be covered as in-network. The 
Plan denied your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The submission of claims using individual gene 
CPT codes, when either 5-50 or greater than 50 gene panels are ordered, is considered incorrect coding. When 
a panel with greater than one or less than five genes is ordered, use the corresponding existing panel CPT code 
or CPT code 81479 if none exists. 
 
We find that CPT codes 81206 and 81292 are not supported in the medical record. Specifically, these codes 
were used to report a panel, which should be billed with a single code. Based on this information, we decided 
that Medicare rules for coverage of a Tempus Gene Panel have not been met. Therefore, we decided that the 
Plan does not have to pay for a Tempus Gene Panel (81206, 81292) provided on August 5, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care to be 
provided by a network facility. 
 
 
 
 You asked the Plan to pre-approve the continuation of SNF care. You say that you need 24-hour care and is not 
well enough to take care of yourself. You say you would be putting yourself in danger if you go home because 
you are in early-stage dementia and a fall risk. The Plan denied your request. The Plan says authorization 
denied because the continuation of SNF care is not medically necessary and does not meet Medicare 
guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the continuation of SNF care. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the 
documentation provided, you no longer qualify for SNF coverage. You do not have documented skilled nursing 
needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, 
can, as a practical matter, be provided at a lower level of care (ex. home, assisted living, long-term 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 the continuation of SNF care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of skilled nursing facility (SNF) care to be provided by a 
network facility.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and 2 or more power seating system motors.  
You asked the Plan to pre-approve an electronic connection between wheelchair controller and 2 or more 
power seating system motors. You say that the services are necessary. The Plan denied your request. The Plan 
says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that power wheelchair accessories are covered when 
specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an electronic connection between 
wheelchair controller and 2 or more power seating system motors. Our reviewer says that the services are not 
medically necessary. Our physician reviewer found upon review of the clinical documentation, electronic 
connection between wheelchair controller and 2 or more power seating system motors there is no evidence to 
show medical necessity, thus the item does not meet coverage requirements. Based on extensive documentation 
regarding left upper limb function, the enrollee would be able to access individual components. 
 
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 electronic connection between wheelchair controller and 2 or more power 
seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
electronic connection between wheelchair controller and 2 or more power seating system motors.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a limited bilateral non-
invasive physiologic study of the upper and lower extremity arteries. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary and you don't want to 
lose your leg. The Plan denied your request. The Plan says there are in-network providers available within a 
reasonable distance. 
 
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 
an out-of-network referral for a limited bilateral non-invasive physiologic study of the upper and lower 
extremity arteries.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment (D6057), an abutment 
supported crown (D6058), and an endosteal implant (D6010) to be provided by a participating provider. 
 
You asked the Plan to pay for a custom fabricated abutment, an abutment supported crown, and an endosteal 
implant. You say that these services are medically necessary. The Plan denied your request. The Plan says the 
requested dental services are not covered 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 pay for a custom 
fabricated abutment (D6057), an abutment supported crown (D6058), and an endosteal implant (D6010) 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 dental implant placement (D6010) for tooth #14. 
 
You asked the Plan to pre-approve a dental implant. You say that this service is necessary, and without this 
implant you could lose more teeth. 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 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 
dental implant placement (D6010) for tooth #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental implant (D6010) for tooth #14. 
 
You asked the Plan to pre-approve the dental implant. You say that this service is necessary, and you cannot 
find any in-network providers to do this work. The Plan denied your request. The Plan says the requested 
service is not covered by your dental benefit, regardless of the status of the rendering provider. In addition, 
your benefit does not have coverage for out-of-network services. 
 
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 
dental implant (D6010) for tooth #14.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. You say that pain has increased since having surgery to 10 
out of 10 and you need therapy for strengthening. You say that you live alone, and your goal is to return home 
to be independent like prior level of care. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for SNF coverage. 
  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the provided records do not 
document a significant decline in your functional status to necessitate daily inpatient skilled therapy services. 
Services in a long-term care facility on a part time basis are more appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an Office Visit provided on November 30, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for an Office Visit. You say that you are requesting reconsideration because you 
dont need an authorization based on your contract. The Plan denied your request. The Plan says the provider is 
out-of-network and it was determined these services were not urgent or emergent. 
 
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 an Office Visit provided on November 30, 2021 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 14 implant supported crowns (D6065). 
 
You asked the Plan to pre-approve the dental services. You say that you are unable to chew or eat since you are 
missing all of your teeth. The Plan denied your request. The Plan says dental implants and all associated 
services are excluded from coverage. 
 
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 implant supported 
crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve 14 implant supported crowns (D6065).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit on August 20, 2021. 
 
You asked the Plan to waive the copayment for office visit. You say that there should be no copayment because 
this was a physical exam. The Plan denied your request. The Plan says copayment is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $10 
copayment for each Medicare-covered visit with an in-network primary care physician (PCP).  
 
You have been asked to pay $10 copayment for office visit. The office visit falls within the Physician/ 
Practitioner services, including doctor's office visits benefit category. The medical records show this visit was 
for chronic disease management, which is not considered an annual physical. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for office visit on August 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental item. You say that you feel a lot of pain. You also say that you 
cannot eat well. The Plan denied your request. The Plan says coverage for a partial lower denture is limited to 
once every 60 months. The Plan also says that 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 lower denture is covered 
once every 60 months, the frequency limit has been reached. The record shows that the Plan approved a partial 
lower denture on February 24, 2022. Therefore, we decided that the Plan does not have to pre-approve a partial 
lower denture (D5214).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided from 
November 30, 2021, to December 2, 2021. 
 
You asked the Plan to waive the copayment for emergency room visit. You say that it was medically necessary 
to be admitted to the ER. The Plan denied your request. The Plan says the copayment was applied correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for in-network emergency services.  
 
 
  You have been asked to pay $90 for an emergency room visit. Emergency room visit falls within the 
Outpatient hospital observation benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
the emergency room visit provided from November 30, 2021, to December 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no medically accepted indication for Keytruda. 
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has been 
treated with doxorubicin and cyclophosphamide, followed by paclitaxel, radiation therapy, tamoxifen and 
letrozole. In April, 2022, the enrollee was diagnosed with ocular nerve sheath involvement (CNS 
carcinomatosis) with triple negative metastatic breast cancer. The documentation does not support that use of 
Keytruda in this setting is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
 
You asked the Plan to pre-approve SNF services. Plan denied your request. The Plan says services can safely 
be received in another setting. 
  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that the provided records do not 
document a significant decline in your functional status to necessitate daily inpatient skilled therapy services. 
Services in the home with home health care or in a long-term care facility on a part time basis are more 
appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal orthotic device (D7880). 
 
You asked the Plan to pre-approve an occlusal device. You say that this item is necessary to stabilize the 
enrollee's mandible and neck alignment. The Plan denied your request. The Plan says this service is not covered 
by the enrollee's dental benefit. An occlusal device is considered to be a dental device and not durable medical 
equipment. Splints are covered under the durable medical equipment benefit only when they are used to treat 
obstructive sleep apnea. 
 
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 
occlusal orthotic device (D7880).