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

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested ventilator is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has obesity-hypoventilation syndrome, and was recently hospitalized with hypercarbic respiratory failure and 
pneumonia. The enrollee is now in a nursing facility. The arterial blood gas prior to discharge showed mild 
C02 retention. There is a listed diagnosis of chronic obstructive pulmonary disease, but no supportive data for 
that diagnosis.  Bilateral positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) has not 
been tried and failed in the nursing home.  The patient responded well to BiPAP in the hospital. Medicare does 
not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on December 29, 2021. 
 
You asked the Plan to waive the coinsurance for an injection. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
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 20% 
coinsurance for in-network Part B drugs.  
 
You have been asked to pay $30.54, which is 20% of the allowed amount for an injection ($152.70 allowed 
amount x 20% coinsurance = $30.54). An injection falls within the Medicare Part B Prescription Drugs 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 coinsurance for an injection provided on December 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the specialist office visit provided on December 6, 2021 by 
an out-of-network (OON) Podiatrist. 
 
You asked the Plan to pay for the specialist office visit. You say that the enrollee said they were covered under 
Medicare. The Plan denied your request. The Plan says the services were provided out-of-network and were not 
approved in advance. 
 
 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 specialist office visit provided on December 6, 
2021 by an out-of-network (OON) Podiatrist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system, Blue Egg switch, Stealth 
Height adjustable receiver, and attendant control. 
 
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 covered. 
 
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) and power 
standing feature (E2301) are non-covered because they are not primarily medical in nature. The rules say that 
adjustable height armrests (E0973, K0020) may be billed separately. If an attendant control (E2331) is 
provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. 
We looked at the file and Medicare rules. The requested power seat elevation system is not covered by 
Medicare. The Blue Egg switch is not covered because it is already included in the approved expandable 
controller upgrade. The requested Stealth Height receiver is requested under code K0108 but should be 
requested under code E0973. The attendant control is not covered because it cannot be included with the 
approved beneficiary-operated joystick. Therefore, we decided that the Plan does not have to pre-approve a 
power seat elevation system, Blue Egg switch, Stealth Height adjustable receiver, and attendant control.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that the enrollee needs their maxillary 
partial denture (D5213) to be replaced due to losing tooth #10. You also say that their current partial no longer 
fits. The Plan denied your request. The Plan says the enrollee exceeded their limit of 1 maxillary denture per 5 
calendar 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dentures are limited to 1 set every 5 
years. The record shows that the enrollee received a maxillary partial denture (D5213) on February 8, 2021 and 
the enrollee's maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have 
to pre-approve a maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and periapical x-ray 
(D0220) provided on November 19, 2021. 
 You asked the Plan to pay for the dental services. You say that this was an emergency. You also say that the 
enrollee was in extreme pain. The Plan denied your request. The Plan says dental services performed out of 
network are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services performed out of 
network are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for the limited oral evaluation (D0140) and periapical x-ray (D0220) provided on November 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repair/accessories (K0108x3, E2224, 
E2211, E2213, E2205). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee needs replacement wheels, tires, and inserts, which can be met with a 
K0070 x2 to meet needs. 
 
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 E2205, E2224, E2211 and E2213 are not medically necessary, as they are included in the approved 
K0070x2 replacement wheels, tires, and inserts. This request exceeds your needs. The various accessories 
coded with K0108 also exceed your medical need, as Medicare does not pay for any items or services that are 
not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of 
a malformed body member. 
 
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 power wheelchair repair/accessories (K0108x3, E2224, E2211, E2213, E2205).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve total knee arthroplasty (medial and lateral) with 
computer-assisted navigation for the enrollee. 
 
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 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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the health plan has approved the requested 27446- arthroplasty, knee, condyle, and plateau, medial OR 
lateral compartment. Detailed documentation is not evident regarding the need for the additional requested 
code of 27447- arthroplasty, knee, condyle, and plateau, medial AND lateral compartments with or without 
patella resurfacing. (The provider would not typically be able to perform a partial knee replacement and a total 
knee replacement at the same time.)  Additionally, computer-assisted total knee arthroplasty is not supported by 
evidence-based medical guidelines or peer-reviewed literature. There is no large volume, high quality clinical 
trials that confirm the clinical benefits (ultimate outcomes of functionally improvement and pain reduction) of 
computer-assisted surgery over standard surgical approaches in total knee arthroplasty. Therefore, the 
requested right total knee arthroplasty (medial and lateral) with computer-assisted navigation (CPT 27447 and 
0055T), in this case, 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve total knee arthroplasty (medial and lateral) with computer-assisted navigation for the 
enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated stainless-steel crown (D2931) provided by a 
participating provider on November 30, 2021. 
 
You asked the Plan to pay for a prefabricated stainless-steel crown. You say that you do not understand why 
the dentist is in-network and the services were not covered. The Plan denied your request. The Plan says D2931 
is not a covered 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 pay for a 
prefabricated stainless-steel crown (D2931) provided by a participating provider on November 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. 
 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 admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the patient requires skilled nursing services, i.e., the 
specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and 
effectively provide medically necessary and reasonable treatment. The records do not document the need for 
intravenous medications, new tube feeding or ostomy care or daily complex wound care. The patient does not 
require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are 
not required to safely and effectively provide medically necessary and reasonable treatment. The patient is 
walking and transferring independently with no reported needs. There is no documentation that daily skilled 
services are required. Based on the medical records provided, there is no documentation that the patient 
requires the services on an inpatient basis, only in a skilled nursing facility setting. Follow-up with an 
outpatient wound care specialist and with his primary medical provider appears to be indicated 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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (E2377) with the related 
electronic connection (E2311) and harness (E2313) for an approved power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller and related hardware. You say that the requested 
accessories should be approved. The Plan denied your request. The Plan says all requested items have been 
approved aside from the expandable controller which is not found to be 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 the expandable controller and related 
hardware. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case.  
Our physician reviewer found the provided records document that the enrollee has 3+/5 upper extremity 
strength with no reported limitations of either hand, and he is independent with feeding, upper extremity 
dressing, and toileting, thus indicating he has adequate upper extremity strength and function to operate the 
wheelchair's power options with their own switches.  
 
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 expandable controller and related hardware have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the expandable controller (E2377) with the related 
electronic connection (E2311) and harness (E2313) for an approved power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided by a 
participating provider on October 7, 2021. 
 
You asked the Plan to pay for a mandibular partial denture. You say that you would like the Plan to pay for 
this. The Plan denied your request. The Plan says the benefit maximum allowance amount of $3,000 has 
already been met and exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum 
allowance amount of $3,000 for dental benefits.  
 
We looked at the file and Medicare rules. Evidence was provided to show that the dental maximum allowance 
amount had already been exhausted. Based on this information, we decided that the Plan's rules for coverage of 
a mandibular partial denture have not been met. Therefore, we decided that the Plan does not have to pay for a 
mandibular partial denture (D5214) provided by a participating provider on October 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a complete 
radiographic imaging (D0210), and panoramic radiographic imaging (D0330) provided by a participating 
provider on December 7, 2021. 
 
You asked the Plan to pay for a comprehensive oral evaluation, a complete radiographic imaging, and 
panoramic radiographic imaging. You say that you should not be responsible for the denied amount. The Plan 
denied your request. The Plan says the benefit limit for the dental services provided have 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 Plan's coverage rules apply in this case. The Plan covers a 
comprehensive oral evaluation once every three years, and a complete radiographic imaging and panoramic 
radiographic imaging once every five years. We looked at the file and Medicare rules. Evidence was provided to show that these dental services were provided on December 16, 2019. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, a complete radiographic imaging, and panoramic radiographic imaging have 
already been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation 
(D0150), a complete radiographic imaging (D0210), and panoramic radiographic imaging (D0330) provided by 
a participating provider on December 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prednisone 20 mg tablet. 
 
You asked the Plan to pre-approve Prednisone. You say that this drug is medically reasonable and necessary 
for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the 
enrollee's medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone 20 mg tablet.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an abutment supported cast metal crown (D6063) and 
an implant supported crown (D6066). 
 
You asked the Plan to pre-approve the abutment supported cast metal crown and implant supported crown. You 
say that you need the implants because you cannot eat well and are in a lot of pain. The Plan denied your 
request. The Plan says these services are not covered under your benefit 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 an 
abutment supported cast metal crown (D6063) and an implant supported crown (D6066).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that the patient received the previous device more than 
five years ago. The Plan denied your request. The Plan says the records show that the same device was received 
in May 2019. 
 
The Plan must follow Medicare rules. Medicare rules say that the typical durable medical equipment 
reasonable useful lifetime is five years. 
 
The same device was received less than five years ago in 2019. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 hours of home health aide care. 
 
You asked the Plan to pre-approve 7 hours of home health aide care. You say that this care is medically 
reasonable and necessary. The Plan denied your request. The Plan says there is no medical necessity for 
additional hours of home health aide beyond what has been approved. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 7 hours of home health aide care.  Our reviewer says that the requested home health aide care is not medically reasonable and necessary. Our 
physician reviewer found the provided records do not clarify why seven hours of home health aide services are 
required and records do not document a need which would necessitate additional services beyond what have 
been approved. No medical notes from your treating physician are provided documenting a need for seven 
hours of home health aide services versus five hours per day.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 7 hours of home health aide care have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 7 hours of home health aide care.