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

 
We decided that the Plan does not have to pre-approve the queen-sized incontinence bed pad. 
 
You asked the Plan to pre-approve the queen-sized incontinence bed pad. You say that this is necessary for 
your condition. The Plan denied your request. The Plan says this is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the queen-sized incontinence bed pad.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zometa. 
 
You asked the Plan to pre-approve Zometa. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested use is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Zometa. Our reviewer says that the 
requested use of Zometa is not supported. Our physician reviewer found the record indicates that the enrollee 
has a diagnosis of hypercalcemia related to noncaseating granulomas. The Food and Drug Administration has 
not stated that the requested drug is indicated for the enrollee's condition. The Medicare-approved drug 
compendia also do not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zometa have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zometa.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction on December 2, 2021. 
 
You asked the Plan to pay for an extraction. You say that you would like to appeal the cost share. The Plan 
denied your request. The Plan says the 50% coinsurance applied is correct. 
 
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 
extraction on December 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure on teeth numbers 5 and 29 for 
isolation of tooth with rubber dam (D3910), a canal preparation and fitting of preformed dowel or post for teeth 
numbers 5 and 29 (D3950), and drugs or medicaments dispensed in the office for home use (D9630) to be 
provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you are a low-income person and cannot 
afford the dental services. The Plan denied your request. The Plan says the denial to pre-approve the dental 
services was correct. The Plan says the requested services are not a covered benefit under the benefit package 
that your contract with the Plan offers. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered by this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
surgical procedure on teeth numbers 5 and 29 for isolation of tooth with rubber dam (D3910), a canal 
preparation and fitting of preformed dowel or post for teeth numbers 5 and 29 (D3950), and drugs or 
medicaments dispensed in the office for home use (D9630) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and prophylaxis (D1110) 
provided on August 3, 2021, and a filling on tooth #13 (D2392) provided on September 27, 2021. 
 
You asked the Plan to pay for an evaluation, prophylaxis, and filling. You say that you are on a fixed income 
and these charges will cause a financial hardship. You also say you were not told the provider was out-of-
network with the Plan. The Plan denied your request. The Plan says the services are not covered when seen by 
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 Plan's coverage rules apply in this case. 
 
The record shows you received 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 when received 
by an out-of-network provider. Therefore, we decided that the Plan does not have to pay for a periodic oral 
evaluation (D0120) and prophylaxis (D1110) provided on August 3, 2021, and a filling on tooth #13 (D2392) 
provided on September 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ilumya (J3245). 
 
You asked the Plan to pre-approve Ilumya. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy requirements have not been 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 Ilumya. Our reviewer says that the 
requirements for coverage of Ilumya have not been met. Our physician reviewer found the Plan requires a trial 
of Stelara and Remicade, Inflectra, or Infliximab before they will approve the requested drug. The provided 
records do not indicate that the enrollee has tried and failed the required drugs. the records also do not indicate 
that the required drugs would be less effective or have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Ilumya (J3245).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation (E2300) and enhanced steering 
and controller for a power wheelchair (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve a power seat elevation and enhanced steering and controller for a power 
wheelchair. You say that you really need this power wheelchair as this is your only way of moving around. The 
Plan denied your request. The Plan says these items do 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.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevation (E2300) and enhanced steering and 
controller for a power wheelchair (E2311, E2313, E2377).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with acute hypoxic respiratory failure and acute kidney injury in the setting of severe sepsis from 
pneumonia. The record indicates that the enrollee requires acute care services before transitioning to a lower 
level of care.    The enrollee continues to receive acute care services, and these have not been denied. The 
medical record does not indicate that the enrollee requires services that he is not currently receiving but that 
would be available at the LTACH facility. The elements of the coverage rules 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that this device is medically necessary. The Plan 
denied your request. The Plan says the requested home ventilator is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home ventilator. Our reviewer says 
that the requested home ventilator is not medically reasonable and necessary. Our physician reviewer found a 
home ventilator is not medically necessary. This patient has COPD and heart failure with preserved ejection 
fraction (HFpEF) and was recently hospitalized with exacerbation of both.  Arterial blood gas (ABG) was 
consistent with acute-on-chronic CO2 retention.  But there is no ABG when stable as an outpatient to confirm 
chronic CO2 retention.  If the patient does have chronic CO2 retention, bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) would be appropriate support sand has not 
been tried at home.  Medicare does not cover a home ventilator when used as BiPAP. The denial is upheld. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oncology (prostate) microarray gene expression profile 
testing provided on January 14, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for genetic testing. You say that this testing was ordered by the treating physician to 
guide them through the process of selecting appropriate treatment. The Plan denied your request. The Plan says 
the denial of payment for this testing is correct, because authorization for this testing was denied and this test is 
not covered by Medicare. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The requested provider in this case is not a network provider with the Plan. Prior authorization for this testing 
was requested and clearly denied by the Plan. We found no exception that would require the Plan to pay for 
these items/services. Therefore, we decided that the Plan does not have to pay for oncology (prostate) 
microarray gene expression profile testing provided on January 14, 2022 by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an X-Spine Axle Interspinous device. 
 
You asked the Plan to pre-approve an X-Spine Axle Interspinous device. You say that the requested X-Spine 
Axle Interspinous device is medically necessary. The Plan denied your request. The Plan says the requested X-
Spine Axle Interspinous device is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an X-Spine Axle Interspinous device. 
Our reviewer says that the requested X-Spine Axle Interspinous device is not medically necessary. Our 
physician reviewer found the requested X-Spine Axle Interspinous device remains experimental. More research 
is needed. At this time, the device 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 an X-Spine Axle Interspinous device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an X-Spine Axle Interspinous device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the seat elevator (CPT code E2300) and complete 
armrests and all necessary parts (CPT code K0108 X 5). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the DME have not been met. The seat lift and functional reach do 
not serve a medical purpose and cannot be covered. The extra elbow supports cannot be covered, as duplicate 
services cannot be covered by Medicare. The complete armrests and all necessary parts are already included 
with the wheelchair and cannot be covered separately. Therefore, we decided that the Plan does not have to 
pre-approve the seat elevator (CPT code E2300) and complete armrests and all necessary parts (CPT code 
K0108 X 5).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), a periodic oral evaluation (D0120), 
and a panoramic x-ray (D0330) provided on January 13, 2022. 
 
You asked the Plan to pay for prophylaxis, evaluation, and x-ray. You say that you checked the 2022 provider 
list and your appointment had to be made three months in advance. The Plan denied your request. The Plan 
says the services are not covered when seen by 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. 
 
The record shows you received 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 among those covered 
under this benefit when received by an out-of-network. Therefore, we decided that the Plan does not have to 
pay for prophylaxis (D1110), a periodic oral evaluation (D0120), and a panoramic x-ray (D0330) provided on 
January 13, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that the requested Durolane is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Euflexxa first. 
 
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 Durolane. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the record indicates that the 
enrollee has osteoarthritis of the knees. The requested medication is a new start. 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 Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied 
your request. The Plan says you have oxygen tanks available that meet your needs. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 concentrator Our reviewer says that 
the requested concentrator is not medically reasonable or necessary. Our physician reviewer found you have 
portable oxygen tanks. There are no medical records indicating that these tanks fail to meet your needs for 
portable oxygen. There is no ambulatory oxygen testing showing that SpO2 is at least 90% while exercising 
with an oxygen conserving device and flow rate 1 - 4 L/min. 
 
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 concentrator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a portable oxygen concentrator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam CT capture (D0367), and an endosteal 
implant (D6010) for teeth #18 and #20, provided by a participating provider. 
 
You asked the Plan to pre-approve a cone beam CT capture and an endosteal implant. You say that you would 
like the Plan to approve these services. The Plan denied your request. The Plan says the requested services are 
not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, 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 a 
cone beam CT capture (D0367), and an endosteal implant (D6010) for teeth #18 and #20, provided by a 
participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs continued care at a 
LTACH upon discharge from his acute inpatient hospitalization. The Plan denied your request. The Plan says 
the enrollee is receiving appropriate inpatient acute care and does not require transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical record does not indicate that the enrollee requires services that he is not 
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are 
not satisfied. Our reviewer also found that 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.