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

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided February 21, 2022. 
 
You asked the Plan to pay for the tooth extraction. You say that this service should be covered. The Plan 
denied your request. The Plan says this service is not covered under your 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided February 21, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tagrisso tablets. 
 
You asked the Plan to pre-approve Tagrisso tablets. The Plan denied your request. The Plan says Tagrisso is a 
self-administered drug and does not fall under Part B coverage. 
 
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 Tagrisso tablets.  
 Benefits for Tagrisso tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prochlorperazine. 
 
You asked the Plan to pre-approve Prochlorperazine. You say that you are using this medication for the 
enrollee's iron infusion related nausea. The Plan denied your request. The Plan says Prochlorperazine is a self-
administered drug and does not fall under Part B coverage. 
 
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 Prochlorperazine.  
 
Benefits for Prochlorperazine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal 
implants (D6010). 
 
You asked the Plan to pre-approve endosteal implants. You say that this is the cheapest option, and you would 
like the Plan to cover it. The Plan denied your request. The Plan says this service is not covered under your 
benefits. Additionally, any covered services must be performed by a participating general dentist. 
 
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 the 
surgical placement of implant body: endosteal implants (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fluid circulating cold pad with pump (E0218). 
 You asked the Plan to pre-approve a fluid circulating cold pad with pump. You say that you are having right 
knee replacement surgery. You also say that due to reconstruction on your knee, an ice machine/cold pack is 
needed because you live alone, you have compression which will assist in the healing process, and it will help 
to keep bacteria from getting into the incision causing an infection. It will also reduce the pain and swelling. 
The Plan denied your request. The Plan says the requested equipment is non covered as it is not medically 
reasonable or necessary. 
 
The Plan must follow Medicare rules. The rules say that a fluid circulating cold pad with pump will be denied 
as not reasonable and necessary.  
 
While a fluid circulating cold pad with pump may be appropriate in this case, the Plan does not offer coverage 
for this item. Therefore, we decided that the Plan does not have to pre-approve a fluid circulating cold pad with 
pump (E0218).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis. 
 
You asked the Plan to pre-approve Eliquis. You say that Eliquis is the best treatment option for 
thromboembolic stroke prophylaxis. The Plan denied your request. The Plan says Eliquis is a self-administered 
drug and does not fall under Part B coverage. 
 
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 Eliquis.  
 
Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental extractions (D7140), and anesthesia (D9222 and 
D9223) provided by an out-of-network provider on January 17, 2022. 
 
You asked the Plan to pay for dental extractions and anesthesia. You say that you were told that you would be 
reimbursed for these services. The Plan denied your request. The Plan says this claim has been processed 
correctly. 
 
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.  
 
We looked at the file and Medicare rules. The first two extractions were covered at a 50% coinsurance. Any 
extractions provided after the allowed two is not covered by the Plan. Based on this information, we decided 
that the Plan's rules for coverage of dental extractions and anesthesia have not been met. Therefore, 
we decided that the Plan does not have to pay for dental extractions (D7140), and anesthesia 
(D9222 and D9223) provided by an out-of-network provider on January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a chair and seat lift mechanism. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section are met. The rules say that a chair 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the submitted records do not contain 
imaging evidence that you have severe arthritis of the hip or knee or neuromuscular disease. The seat lift is not 
likely to help improve your condition or stop or slow deterioration of your condition. The records do not show 
that you are completely incapable of standing from a chair in your home. You are able to ambulate. The criteria 
for coverage are not met and the seat lift mechanism are not reasonable or medically necessary.  
We looked at this physician's review, the file, and Medicare rules. The physician reviewer found that the seat 
lift mechanism is not medically necessary. The Plan must provide coverage only for items that Medicare 
covers, and the seat lift chair is not covered. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a chair and seat lift mechanism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a scooter (E1399). 
 
You asked the Plan to pre-approve a scooter. You say that the item is medically necessary. The Plan denied 
your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
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 for the scooter. Our reviewer says that the item is not medically necessary.  Our physician reviewer found the documentation does not support that the member 
intends to use the power mobility device in the home to accomplish mobility-related self-care tasks. 
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a scooter (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Femtosecond laser. 
 
You asked the Plan to pre-approve Femtosecond laser. 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 must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Specifically, medical records were not provided. Without this 
documentation, medical necessity is not able to be established. The provider was unable to perform the laser 
assisted portion of the surgery, only a regular cataract surgery was performed. Based on this information, we 
decided that Medicare rules for coverage of Femtosecond laser have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Femtosecond laser.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional denture clasp (D5660), an additional tooth for a 
denture (D5650), topical fluoride application (D1208), a core build-up (D2950), and a crown (D2740), 
provided by a participating provider on September 27, 2021, to October 4, 2021. 
 
You asked the Plan to pay for an additional denture clasp, an additional tooth for a denture, topical fluoride 
application, a core build-up, and a crown. You say that the Plan paid for some of this, but not all of it. You say 
that you would like the Plan to pay for the rest. The Plan denied your request. The Plan says the services in 
question have been processed correctly. 
 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 an 
additional denture clasp (D5660), an additional tooth for a denture (D5650), topical fluoride application 
(D1208), a core build-up (D2950), and a crown (D2740), provided by a participating provider on September 
27, 2021, to October 4, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve weight loss surgery. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that they are unable to assess for morbid obesity, psychological 
evaluation, exercise regimen, or previous weight loss attempts without clinical documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. You are an adult, with 
BMI that is greater than 35 kg/m2 (49), multiple obesity conditions including sleep apnea and hypertension and 
have failed conservative efforts at weight loss. Our physician reviewer found that your condition meets criteria 
for coverage of weight loss surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve weight loss surgery.  
 
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: 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 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 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 based on the medical records provided there is no documentation that you require the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Records do not clarify 
that treatment at the skilled nursing facility level is not 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 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: 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 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 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 medical and rehabilitation needs does not require an acute hospital inpatient rehab stay with an interdisciplinary approach to rehabilitation care. Documentation 
does not support the medical necessity for admission to an IRF. 
 
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 power wheelchair accessories (E2377, E2311, E2313, 
E2331, and K0108). 
 
You asked the Plan to pre-approve power wheelchair accessories. You say that the remaining accessories are 
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the 
remaining accessories. 
 
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 power wheelchair accessories. Our 
reviewer says that the enrollee does not meet criteria for the remaining accessories. Our physician reviewer 
found based on the medical records provided there is no documentation that the enrollee has a covered 
indication for the requested expandable controller (E2377), expandable controller harness (E2313), and 
electronic connection (E2311) to control power tilt, recline and power elevating leg rests through the joystick. Provided records document that the enrollee can feed, groom, bathe and dress herself at times and also use of 
her phone thus indicating she has adequate upper extremity strength and function to operate the wheelchairs 
power options with their own switches. There is no documentation that the enrollee meets criteria for the 
requested attendant control (E2331). As stated in the Local Coverage Article: Wheelchair Options/Accessories 
- Policy Article (A52504): "If an attendant control (E2331) is provided in addition to a beneficiary-operated 
drive control system, it will be denied as non-covered." 
 
The rules also state that for equipment to be covered, it must be appropriate and needed for use inside the 
home.  
 
The requested transit option (K0108) is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve power wheelchair accessories (E2377, E2311, E2313, E2331, and K0108).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (urothelial), mRNA, gene expression profiling by 
real-time quantitative PCR of five genes (0012M) provided November 11, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that you believe the evidence supporting the use of 
Cxbladder as a medically necessary diagnostic service is well established and affirmed by Medicare. The Plan 
denied your request. The Plan says this service does not meet Medicare's criteria of medically reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. This test has not been evaluated by the MolDx Programs technical 
assessment process and LCD L35396 cites it as noncovered. Based on this information, we decided that 
Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of 
five genes (0012M) provided November 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint. 
 
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. 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 must follow Medicare rules. Medicare rules say that radiofrequency ablation used for sacro-iliac joint 
pain is considered not medically necessary/investigational whether performed using traditional, cooled, or 
pulsed radiofrequency.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of radiofrequency ablation to the SI joint have not been met. Therefore, we decided that the Plan does 
not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Orion Knee (L5828, L5845, L5848, L5856) for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs this for his safety while 
walking outside and on uneven terrain. The Plan denied your request. The Plan says that the member does not 
meet medical necessity for microprocessor knee since a non-computerized prosthesis is available to meet the 
member's K level. 
 The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The requested 
microprocessor knee has deluxe features such as a recessed covered magnetic charging point, Android and iOS 
app programming, and a button programming functioning and a cycling mode all of which exceed the patient's 
medical needs. The physician documentation does not reveal that the patient requires a microprocessor knee 
over a K3 mechanical knee. The requested Orion knee exceeds the patient's medical needs. Our physician 
reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Orion Knee (L5828, L5845, L5848, L5856) for the enrollee.