Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pay for the Bupivacaine (J3490) provided on November 7, 2022. 
 
You asked the Plan to pay for the Bupivacaine. The Plan denied your request. The Plan says that this service is 
not covered. The Plan also says these services were not authorized to be done by a non-participating provider. 
 
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. The records do not support that this service is not authorized. This means that 
the Plan has not provided a valid reason for denying payment of the Bupivacaine. 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 pay for the Bupivacaine (J3490) provided on 
November 7, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee requires 24-hour care. You 
also say that these supplies are necessary for the enrollee. The Plan denied your request. The Plan says the 
requested supplies are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve CGM. You say that this will help better control the enrollee's levels. You 
also say that it would prevent hospital visits. The Plan denied your request. The Plan says the requested CGM 
is not covered. 
 
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 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 
continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that the item is medically necessary. 
The Plan denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 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 pre-approve compression 
stockings identified with code A6549.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement foot for a prosthesis. 
 
You asked the Plan to pre-approve a replacement foot. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested device is not covered. 
 The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that the enrollee has a current foot for the prosthesis. The enrollee's current foot serves the same 
purpose as the requested foot. The documentation shows that the enrollee's current foot is under warranty as it 
is less than 36 months old. Medicare does not cover replacement costs for items still under warranty. Therefore, 
we decided that the Plan does not have to pre-approve a replacement foot for a prosthesis.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a radiofrequency ablation (RFA) procedure of the 
genicular nerve (64624). 
 
You asked the Plan to pre-approve an RFA of the genicular nerve. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says the requested services are 
experimental/investigational. 
 
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 RFA of the genicular nerve. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that the role of RFA of the genicular nerves is still being investigated. This is 
considered to be an experimental/investigational procedure. 
 
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 RFA of the genicular nerve have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an RFA procedure of the genicular nerve (64624).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Bupivacaine (J3490) rendered on September 21, 2022. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says the precertification entity was not contacted for precertification. 
 
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 pay for the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found that in this case, 
there is no documentation indicating that there has been a documented failure to respond to non-invasive/ 
conservative care management. Although Bupivacaine is a  safe and effective drug, the procedure is not 
medically reasonable or necessary for this patient 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for Bupivacaine (J3490) rendered on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a service dog for support (S5199). 
 
You asked the Plan to pre-approve a service dog. You say that the enrollee needs continued use of an emotional 
support dog. You also say that the dog is registered as an emotional support animal. The Plan denied your 
request. The Plan says the required supporting documentation was not submitted that identifies the enrollee as 
the owner of the service dog and that the service dog meets the American with Disabilities Act (ADA) service 
dog qualifications. The Plan also says the appeal letter received indicates that the enrollee requires the dog for 
emotional support. 
 
The Plan must follow Medicare rules. Medicare rules say that a Medicare Advantage (MA) plan may offer 
coverage of a supplemental benefit only if it is medically necessary and additional to the benefit covered by 
original Medicare. 
 
 
  We looked at the file and Medicare rules. The Plan is using the ADA definition of a service dog that is 
individually trained to do work or perform tasks for people with disabilities. The work or task a service dog has 
been trained to provide must be directly related to the persons disability. Dogs whose sole function is to 
provide comfort or emotional support do not qualify as service animals under the ADA. For more information, 
refer to the Americans with Disabilities Act (ADA). Based on this information, we decided that Medicare rules 
for coverage of a service dog have not been met. Therefore, we decided that the Plan does not have to pre-
approve a service dog for support (S5199).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cancer Second Opinion office visit (99205, 99215, 
99449, 88321, 88323, 88325) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a second opinion office visit. You say that the service is medically 
necessary. The Plan denied your request. The Plan says there are in-network providers that can perform this 
service. 
 
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 
a Cancer Second Opinion office visit (99205, 99215, 99449, 88321, 88323, 88325) to be provided by an out-of-
network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair component or accessory, not otherwise 
specified (K0108). 
 
You asked the Plan to pre-approve the power wheelchair repair. You say that you are in need of a prior 
authorization denial in order to pursue the enrollee's secondary insurance that requires formal denial from the 
primary. The Plan denied your request. The Plan says Medicare only covers DME for use in the home and 
Does NOT consider a Skilled Nursing Facility a home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the power wheelchair repair is being requested for use in a SNF or hospital. Therefore, we 
decided that the Plan does not have to pre-approve the wheelchair component or accessory, not otherwise 
specified (K0108).
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. You say that you feel that you should qualify for the 
SSBCI benefit. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. 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 pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that last year you had the utilities benefit, but this 
year you received a denial for this benefit. 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 attempted 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 pre-approve white glass with high gold content cap for bridge 
(D6750) Tooth #4, 6, false tooth for bridge (D6240) tooth #5, implant placement (D6010) Tooth 3, 13, 14, 
custom abutment (D6057) Tooth 3, 13, 14 and abutment supported porcelain fused to metal crown, high noble 
metal (D6059). 
 
You asked the Plan to pre-approve dental services. You say that the requested services are medically necessary. 
The Plan denied your request. The Plan says white glass with high gold content cap for bridge (D6750) and  
false tooth for bridge (D6240) are not medically necessary. 
 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 dental 
services when the services are medically necessary and reasonable. Implant placement (D6010), custom 
abutment (D6057) and abutment supported porcelain fused to metal crown, high noble metal (D6059) are not 
covered under the Plans dental benefits. White glass with high gold content cap for bridge (D6750) and false 
tooth for bridge (D6240) are covered if medically 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 dental services. Our physician reviewer 
found the documentation provided does not meet the criteria for coverage for a fixed bridge replacing tooth #5. 
 
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 dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve white glass with high gold content cap for bridge (D6750) Tooth #4, 6, and false tooth for 
bridge (D6240) tooth #5. The Plan does not have to pre-approve implant placement (D6010) Tooth 3, 13, 14, 
custom abutment (D6057) Tooth 3, 13, 14 and abutment supported porcelain fused to metal crown, high noble 
metal (D6059) because they are not covered under the Plans dental benefits.
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. You say that these additional benefits would help the 
enrollee. The Plan denied your request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that the enrollee does not have 
an eligible condition that meets all the required criteria. 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 pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you need these benefits. The Plan denied your 
request. The Plan says the criteria for eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve destruction procedure provided on August 22, 
2022. 
 
You asked the Plan to pay for the nerve destruction procedure. You say that the records provided support 
medical necessity. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the nerve destruction 
procedure provided on August 22, 2022.
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. You say that you feel you meet criteria for benefits. The 
Plan denied your request. The Plan says medical records were not provided to review whether criteria for 
benefits are met. 
 
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. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient care provided from August 7, 2022, to  
August 31, 2022. 
 
You asked the Plan to pay for inpatient care. You say that the care was medically necessary. The Plan denied 
your request. The Plan says no clinical information was submitted for any days from August 7, 2022, to  
August 31, 2022, to determine medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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 inpatient care have been met.  Therefore, we decided that the Plan does not have to pay for inpatient care provided from August 7, 2022, to 
August 31, 2022.
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. You say that you have severe medical conditions, and 
would like the Plan to reconsider this case. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).