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

 
We decided that the Plan does not have to pre-approve the periodontal scaling and root planing (D4341) 
 
You asked the Plan to pre-approve the dental service. You say that the requested procedure is necessary, so you 
do not lose any more teeth. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because the periodontal scaling and root planing is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
periodontal scaling and root planing (D4341)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth # 11 (D3310), 
maxillary partial denture  tooth #1 (D5213), and mandibular partial denture tooth # 17 (D5214). 
 
You asked the Plan to pre-approve codes D3310, D5213, and D5214. The Plan denied your request. The Plan 
says these services are not covered under the benefit package. 
 
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 
endodontic therapy, anterior tooth # 11 (D3310), maxillary partial denture  tooth #1 (D5213), and mandibular 
partial denture tooth # 17 (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the CPAP supplies provided on September 
28, 2022. 
 
You asked the Plan to waive the coinsurance for the CPAP supplies. You say that these supplies were shipped 
out late and you had ordered a replacement already. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for in-network Medicare-covered durable medical equipment.  
 
You have been asked to pay $37.37, which is 20% coinsurance of the allowed amount for the CPAP supplies. 
These items/services fall within the Medicare-covered durable medical equipment 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 the CPAP supplies provided on September 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the personal attendant services. 
 
You asked the Plan to pre-approve the personal attendant services. You say that the requested services are 
medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare does not cover the 
requested services. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the personal attendant services have not been met. Specifically, we find that the services at issue in 
this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pre-approve 
the personal attendant services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that you need this item. The Plan denied your 
request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that this is medically necessary. The 
Plan denied your request. The Plan says the enrollee must be between 50 and 77 years of age. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 
   
We reviewed the file and the Medicare rules. We find that the enrollee is not between 50 and 77 years of age. 
Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) 
scan for lung cancer screening.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 enrollee has left knee unilateral 
primary osteaorthritis. He has not tried and failed the Plan's required drugs, Orthovisc or Supartz FX. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Hymovis is 
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Hymovis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the oxygen concentrator provided from 
October 30, 2022, to November 29, 2022. 
 
You asked the Plan to waive the cost sharing for the oxygen concentrator. You say that you do not agree with 
the cost sharing applied to this item. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare-covered durable medical equipment, which includes oxygen equipment. 
 
 
 
 
 You have been asked to pay a $19.29 coinsurance for the oxygen concentrator ($96.46 allowed amount x .20 = 
$19.29). This item/service falls within the durable medical equipment (DME) and related supplies 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 cost sharing for the oxygen concentrator provided from 
October 30, 2022, to November 29, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Remicade. 
 
You asked the Plan to pre-approve Remicade. You say that the enrollee may need a partial colectomy without 
treatment. The Plan denied your request. The Plan says the enrollee has not tried one of the preferred drugs. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Remicade. Our physician reviewer 
found that the enrollee has Crohn's disease. The requested medication is a new start. The Plan requires a trial of 
Humira or Skyrizi before they will approve the requested drug. The provided records do not indicate that the 
enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one alternative.  
The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Remicade have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Remicade.
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 services are necessary as you still require daily 
care services. The Plan denied your request. The Plan says your needs can be safely met in a custodial or long-
term care setting. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do have daily skilled nursing needs that require the specialized skill, knowledge, 
and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the 
specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled 
nursing and 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee is at risk of having respiratory failure 
and being readmitted to an acute care hospital. You say that the enrollee's needs cannot be met at a lower level 
of care. The Plan denied your request. The Plan says an IRF admission is not medically necessary, the 
enrollee's needs can be met 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 that the enrollee does not need physician supervision 3 times a week or intensive 
therapy 3 hours a day and 5 days per week with a multidisciplinary approach in an IRF. While the enrollee may 
benefit from physical and occupational therapy the enrollee's needs can be provided in an alternate setting such 
as skilled nursing facility. 
 
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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you need this item. The Plan denied your 
request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve fixed partial denture sectioning (D9120). The Plan denied your request. The 
Plan says this service is not covered under the benefit package. 
 
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 fixed 
partial denture sectioning (D9120).
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G0481 billed for date of service July 27, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that the code is 
redundant to a previously paid code. 
 
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. 
 
We looked at the file and the rules. The Plan denied services as procedure code G0480 was previously billed. 
However, there is no claim information, explanation of benefits, or any other documentation to show that 
additional billing for definitive drug testing was submitted for the date of service at issue. The Plan has not 
made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny 
your request.  Therefore, we decided that the Plan has to pay for procedure code G0481 billed for date of 
service July 27, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation and panoramic 
radiographic image (D0150, D0330) provided on September 7, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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. 
 
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. 
Therefore, we decided that the Plan does not have to pay more for a comprehensive oral evaluation and 
panoramic radiographic image (D0150, D0330) provided on September 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a bone replacement graft for ridge preservation - per 
site D7953 provided on November 15, 2022, and November 21, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the denial and would 
like the Plan to reconsider payment. The Plan denied your request. The Plan says your benefit for the bone 
replacement graft for ridge preservation - per site D7953 dollar limit was met. 
 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. After review, 
it was determined that you had a total of $800.00 available ($400.00) unused from the third quarter rolled 
over). The plan paid $911.00 for codes D0120, D0220, D0230, D2331, D2391, D1110, D1208, and D7210 
provided on November 15, 2022 and November 21, 2022. For code D7953, the plan paid a partial amount of 
$236.00 leaving the remaining amount of $334.00 the members responsibility. The plan has paid the 
maximum benefits for the period and denied correctly. Therefore, we decided that the Plan does not have to 
pay more for a bone replacement graft for ridge preservation - per site (D7953) provided on November 15, 
2022, and November 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Kit Sensor. 
 
You asked the Plan to pre-approve the Freestyle Kit Sensor. The Plan denied your request. The Plan says the 
enrollee does not require insulin three or more times daily. 
 
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 
the Freestyle Kit Sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Kit Sensor.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve second stage implant surgery (D6011) for tooth #10 and tooth #12. 
 
You asked the Plan to pre-approve dental services. You say that the enrollee had prior authorization that 
expired in December 2022. You would like the requested services approved because it is the final phase of 
implant treatment. The Plan denied your request. The Plan says that if the member is already approved for two 
implants or related procedures, this request cannot be approved as it exceeds coverage limits. 
 
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. 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 up to 
two implants per year and covers second stage implant surgery once per tooth per life.  
 
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 Plan states that the benefit for second stage implant surgery on 
the requested teeth has been exhausted. However, the Plan does not provide any evidence that payment has 
been made for second stage implant surgery on these teeth, nor do they provide evidence of any active 
authorizations for payment on these codes. The authorization documents provided show that the issued 
authorization dates have expired. The Plan has not provided information to substantiate their denial reason.  
Therefore, we decided that the Plan has to pre-approve second stage implant surgery (D6011) for tooth #10 and 
tooth #12.  
 
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 a non-preferred brand continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve a non-preferred brand CGM. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says only the preferred brand products listed in 
the EOC are covered. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a CGM. Therefore, we decided that the Plan does not have to pre-approve a non-preferred brand continuous 
glucose monitor (CGM).