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

 
We decided that the Plan does not have to pre-approve a retainer crown (D6740) for tooth #13. 
 
You asked the Plan to pre-approve the dental services. You say that you had four of these approved. 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 has been exhausted with the pre-approval of 
pontics/retainer crowns for tooth #11, #12, #9, and #10. Therefore, we decided that the Plan does not have to 
pre-approve a retainer crown (D6740) for tooth #13.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an adjustment to a partial upper denture (D5421) and to 
pay for an adjustment to a partial lower denture (D5422) provided by an out-of-network provider on November 
3, 2022. 
 
You asked the Plan to pay more for the dental services. You say that your partial dentures did not fit right, and 
you needed them adjusted. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Also, your benefit for the requested dental services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The 
record shows the Plan paid for an adjustment to a partial denture on November 3, 2022; therefore, your benefit 
for the adjustment to a partial denture was exhausted on the date of service of November 3, 2022. Therefore, 
we decided that the Plan does not have to pay more for an adjustment to a partial upper denture (D5421) and to 
pay for an adjustment to a partial lower denture (D5422) provided by an out-of-network provider on November 
3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that 
were issued on December 5, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you need these stockings for different 
uses and need more than the limit allowed. The Plan denied your request. The Plan says you have exceeded the 
limit on the compression stocking benefit. The record shows you received four stockings on November 14, 
2022.  
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6533 that were issued on December 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that acute inpatient rehabilitation is medically necessary 
for the enrollee. The Plan denied your request. The Plan says the enrollee does not have new evolving 
rehabilitation needs, services needed may be safely received at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the item 
does not serve a medical purpose. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 We looked at the file and the rules. The item at issue in this appeal does not serve a purpose that is primarily 
medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation 
system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says 
coverage criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are only covered under 
certain medical indications. 
 
The file shows that a second round of transforaminal (64483 and 64484) injections, and interlaminar (62323) 
injections were requested. 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 requested 
services. Our physician reviewer found that the enrollee has chronic low back pain due to lumbar spinal 
stenosis, lumbar spondylosis, and sacroiliitis. The documentation the epidural steroid injection January 27, 
2023, did not provide 50% of sustained improvement in pain relief for at least three months. The requested 
repeat interlaminar injection is not indicated at this time. A pre-determined second round of transforaminal 
injections is not medically 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve epidural steroid injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept intraosseous nerve ablation system. 
 
You asked the Plan to pre-approve Intracept. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested 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 Intracept. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee was being treated for vertebrogenic low back pain. The enrollee presented with low 
back and right hip pain. The enrollee returns for chronic pain medical management and compliance. The 
enrollee has had persistent right hip and lower back pain. The enrollee has a long history of back pain due to 
scoliosis. There is back pain with radiation of pain to the right hip. The exam of the lumbar spine reveals paraspinal tenderness bilaterally. There is limited extension and bilateral rotation. Bilateral lumbar facets are 
tender. Strength, sensation, and reflexes are intact.  
 
In this case, there were/are multiple plausible pathologic sources of significant pain generation. The persistent 
right hip and lower back pain, diminished extension and bilateral rotation, and intact neurologic exam were/are 
all non-specific to any pathologic entities. Additionally, the magnetic resonance imaging from January 16, 
2023, demonstrated multiple other plausible causes for the low back pain. 
 
Overall, documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the 
spinal vertebral bodies as being the overwhelming primary generators of the enrollees chronic persistent pain. 
The documentation does not support actual formal surgical ablation of pre-designated basivertebral nerves as 
being medically necessary and/or reasonable at this time. There is no compelling rationale presented or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
enrollee does not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Intracept intraosseous nerve ablation system.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee is not ready for discharge and wants 
further skilled therapy. The Plan denied your request. The Plan says medically necessary care may be provided 
safely in a lower level of care. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retainer crown (D6740) - porcelain/ceramic for tooth 
#24 and #26 and pontic - porcelain/ceramic (D6245) for tooth # 25. 
 
You asked the Plan to pre-approve a crown and a pontic for teeth #24 through #26.. You say that this is 
medically necessary. The Plan denied your request. The Plan says this is not medically necessary there is no 
documented physical or neurological disorder present, and no narrative supporting any special needs for this 
member. Therefore, placing a fixed prosthesis (bridge) on teeth #24 - 26 does not meet the coverage criteria. 
 
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 crown and a 
pontic for teeth #24 through #26. when the services are medically necessary and reasonable.  
 
 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 a crown and a pontic for teeth #24 
through #26. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
proposed abutment of tooth #24 is questionable as it has notable bone loss on the mesial aspect and is not a 
suitable terminal abutment for the proposed bridge from #24-26.  The requested services would not meet the 
Plan criteria for fixed bridgework. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown and a pontic for teeth #24 through #26. have not been met. Therefore, 
we decided that the Plan does not have to pre-approve retainer crown (D6740) - porcelain/ceramic for tooth 
#24 and #26 and pontic - porcelain/ceramic (D6245) for tooth # 25.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve special supplemental benefits for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says that based on 
the information submitted, there is no documentation that you meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the records do not support that the Plan made multiple attempts to 
obtain medical records from the provider for this case. The records also show that an attestation from the 
provider was sent to the Plan, but this attestation was not provided with this case. This means that the Plan has 
not provided a valid reason for denying payment of the SSBCI benefits. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in 
your favor. Therefore, we decided that the Plan has to pre-approve special supplemental benefits for the 
chronically ill (SSBCI).  
 
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 special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says based on the 
information submitted, there is no documentation that you meet the criteria. 
 
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 SSBCI benefits have been met. 
Medical records were not provided for this case. The record shows that the Plan made multiple attempts to 
obtain this information, but it was not received. Without medical records we are unable to determine if you 
meet the criteria for coverage. Therefore, we decided that the Plan does not have to pre-approve special 
supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), 
intraoral - periapical first radiographic image (D0220), prophylaxis - adult (D1110) provided on November 22, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the denials of items 1-3 are inconsistent with 
your promoted explanation of covered services. The Plan denied your request. The Plan says prior to the 
processing of this claim, the plan had paid the $1,500.00 maximum allowable for dental services. After the 
annual maximum is exhausted, any remaining charges are the members responsibility. 
 
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 services was exhausted on date of July 28, 2022. Therefore, we decided 
that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), intraoral - 
periapical first radiographic image (D0220), prophylaxis - adult (D1110) provided on November 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of subcutaneous cardiac rhythm monitor 
(33285). 
 
You asked the Plan to pre-approve an implantable loop recorder (ILR). You say that clinical information was 
submitted with the appeal request to support medical necessity. The Plan denied your request. The Plan says 
the requested monitor is considered reasonable and necessary when syncope (passing out) is thought to be 
cardiac-related but is too infrequent to be detected by an external heart monitor. The request to overturn the 
denial of ILR is not granted. 
 
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 an implantable loop recorder (ILR). 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has a history of atrial fibrillation and palpitations. There is 
no documentation provided to suggest a history of unexplained syncope, cryptogenic stroke, or any other 
apparent indication for an ICM. In summary, there is insufficient documentation to support the medical 
necessity for insertion of an ICM in this enrollee's 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 an implantable loop recorder (ILR) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an insertion of subcutaneous cardiac rhythm monitor (33285).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a recement bridge 
(D6930) provided by an out-of-network provider on October 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the EOC states you have $3,000 worth of dental 
coverage and the dental services are a listed as a covered service. The Plan denied your request. The Plan says 
the dental services were received from an out-of-network provider and are not covered by your supplemental 
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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation (D0140) and a recement bridge (D6930) provided by an out-of-network 
provider on October 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestlye Libre 2 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that the enrollee has very sensitive fingers. The Plan 
denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestlye Libre 2 
continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, 
including programming (33285). 
 
You asked the Plan to pre-approve implantable heart monitor. You say that the enrollee is scheduled to undergo 
a cardioversion procedure. She is currently symptomatic and is currently in atrial fibrillation (afib). There are 
additional medical records enclosed. The Plan denied your request. The Plan says the request is not medically 
necessary because records show there is not a question as to whether the enrollee has atrial fibrillation nor do 
the records show that a Holter monitor is contraindicated or will be unrevealing. 
 
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 implantable heart monitor. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee was already diagnosed with afib, without history of significant 
symptoms. With a history of unexplained syncope, the enrollee has requested to undergo a subcutaneous heart 
monitor. The enrollee is also scheduled to have Cardioversion. The implantable heart monitoring does not serve 
any purpose, it is not medically indicated at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of implantable heart monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an insertion, subcutaneous cardiac rhythm monitor, including programming 
(33285).