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

 
We decided that the Plan does not have to pre-approve a porcelain crown (D2750) for tooth number 8. 
 
You asked the Plan to pre-approve the dental services. You say that the original crown was not sealed properly, 
which is why you wanted to replace the crown for tooth number 8. The Plan denied your request. The Plan says 
your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan rules say that they 
cover one crown per every 60 months. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service September 14, 2018. 
Therefore, we decided that the Plan does not have to pre-approve a porcelain crown (D2750) for tooth number 
8.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (71045) provided on February 16, 2022. 
 
You asked the Plan to pay for the x-ray. You say that this service was medically necessary. The Plan denied 
your request. The Plan says the enrollee had elected their hospice benefit at the time of this service. Original 
Medicare is liable for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for an x-ray (71045) provided on February 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the home ventilator is to be used for the 
treatment of CHF and mild to moderate OSAS. The Plan denied your request. The Plan says the request for a 
home mechanical ventilator set in AVAPS mode with or without Auto-EPAP (AE) that could be delivered by 
BiPAP is not covered. 
 
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 service is not medically necessary. Our physician reviewer found the enrollee was recently hospitalized 
with exacerbation of HFrEF, with pulmonary edema and pleural effusions. ABG showed mild CO2 retention 
which improved with treatment. There is also a diagnosis of OSA. There is no diagnosis of COPD, thoracic 
restrictive disease, or neuromuscular disease, so there is no diagnosis for which Medicare covers a ventilator. 
There is no documentation of chronic CO2 retention, with an ABG done while stable as an outpatient. If the 
enrollee does have chronic CO2 retention, she may benefit from BiPAP during sleep. 
 
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 (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services to be provided by the requested out-of-
network provider. 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says dental 
services from an out-of-network provider are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You are requesting dental services from an out-of-network provider. Though the Plan offers a dental benefit in 
excess of Medicare coverage, the requested items or services are not covered under this benefit when received 
from an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve dental 
services to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for topical fluoride and a 2D oral/facial photographic image 
(D0350, D9910) provided on June 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 topical 
fluoride and a 2D oral/facial photographic image (D0350, D9910) provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for periodontal scaling and root planing 
(D4341) on the lower left quadrant, and the extraction of an erupted tooth or exposed root (D7140) for teeth 
numbers 20 and 21 provided on August 8, 2022. We also decided that the Plan does not have to pay for 
gingival irrigation per quadrant (D4921). 
 
You asked the Plan to waive the copayment for periodontal scaling and root planing (D4341) on the lower left 
quadrant, and the extraction of an erupted tooth or exposed root (D7140) for teeth numbers 20 and 21. You also 
asked the Plan to pay for gingival irrigation per quadrant (D4921). You say that you called the Plan asking for 
in-network providers, and the Plan sent you a list. The Plan denied your request. The Plan says this cost sharing 
was charged correctly for periodontal scaling and root planing (D4341) on the lower left quadrant, and the 
extraction of an erupted tooth or exposed root (D7140) for teeth numbers 20 and 21. The Plan also says that 
gingival irrigation per quadrant (D4921) is not a covered benefit per the Plans EOC. 
 
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 $25 
copayment for periodontal scaling and root planing, and for the extraction of an erupted tooth or exposed root.  
 
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 contract also 
excludes gingival irrigation per quadrant from this benefit. 
 
You have been asked to pay a $25 copayment for periodontal scaling and root planing (D4341) on the lower 
left quadrant. You have also been asked to pay a $25 copayment for each extraction of an erupted tooth or 
exposed root (D7140) for teeth numbers 20 and 21. 
 
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 copayment for periodontal scaling and root planing (D4341) on the lower 
left quadrant, and the extraction of an erupted tooth or exposed root (D7140) for teeth numbers 20 and 21 
provided on August 8, 2022.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, gingival irrigations per quadrant 
(D4921) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for gingival irrigation per quadrant (D4921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness upgrade, electronic 
connection between wheelchair controller and two or more electronic devices, shoulder harness, seat elevation 
system, and power standing system. 
 
You asked the Plan to pre-approve an expandable controller, harness upgrade, electronic connection between 
wheelchair controller and two or more electronic devices, shoulder harness, seat elevation system, and power 
standing system. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says 
the requested items are not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. A power seat elevation feature and power standing feature are non-covered. 
 
We looked at the file and Medicare rules. Review of the file shows that  
Upgraded electronics are necessary when there is a medical need to control power options though the joystick. 
The documentation does not support a medical need to control the power options through the joystick. The 
power options can be controlled using their own switches. These switches can be made any size without asking 
for a separate request. They can be made from any material without asking for a separate request. All of this 
can be done without the need to use the joystick to control the power features. The shoulder harness that was 
requested cannot be covered as it is unbundled. The requested seat lift and power standing systems are 
specifically not covered. 
 
Based on this information, we decided that Medicare rules for coverage of an expandable controller, harness 
upgrade, electronic connection between wheelchair controller and two or more electronic devices, shoulder 
harness, seat elevation system, and power standing system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an expandable controller, harness upgrade, electronic connection between 
wheelchair controller and two or more electronic devices, shoulder harness, seat elevation system, and power 
standing system.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says you do not meet 
Medicare criteria for admission to a skilled nursing facility. 
 
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 from a nursing perspective, you received oral medications, a course of intravenous 
vancomycin for four weeks, and had stable vital signs. You received physical and occupational therapy and 
was at supervision to stand by assist level with functional mobility including gait to 150 feet. You also required 
varying assist with activities of daily living skills. You do not 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. 
Our reviewer also found you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in 
a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0140) provided on July 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 3, 2022. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0140) provided on July 6, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (Q4206) provided on December 2, 2021. 
 
You asked the Plan to pay for the injections. You say that this service was medically necessary. The Plan 
denied your request. The Plan says these injections are experimental and non-covered. 
 
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 the injections have been met. No 
clinical records were provided for review. No literature was submitted to support that this procedure is 
medically necessary. Only a procedure note was provided for review. Insufficient documentation was provided to determine medical necessity. Therefore, we decided that the Plan does not have to pay for injections (Q4206) 
provided on December 2, 2021.
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 at this juncture the enrollee should be 
transferred to the LTACH for more extended care. The Plan denied your request. The Plan says the denial of 
authorization for LTACH care is correct. 
 
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 enrollee does not require services at the LTACH that are not available at the 
current acute care hospital. All medically necessary care is being provided in the current acute care 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 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan and a 
computed tomography (CT) scan. 
 
You asked the Plan to pre-approve the PET scan and the CT scan. You say that it is medically necessary for the 
enrollee to have these scans done. The Plan denied your request. The Plan says the enrollee is not currently 
receiving treatment and is on surveillance; therefore, the request does not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 the PET scan and the CT scan. Our 
reviewer says that the requested PET and CT scan is not medically necessary. Our physician reviewer found 
that the enrollee has a history of recurrent malignant melanoma. Per the office note dated August 12, 2022, the 
enrollee has been on a clinical trial but is currently not receiving treatment. The enrollee is on surveillance. Per 
the same office notes, they were originally diagnosed with melanoma in 2016 and had an initial staging 
PET/CT on August 2, 2016. They had a recurrence diagnosed on February 25, 2019. They had follow-up 
PET/CT scans on May 17, 2019, August 19, 2019, November 3, 2019, February 3, 2020, June 10, 2020, 
November 24, 2020, April 1, 2021, and September 14, 2021. In this case there is no specific clinical rationale 
for the requested PET/CT scan. Surveillance/Follow-up, PET/CT scans are not indicated for surveillance. 
 
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 PET scan and the CT scan have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a positron emission tomography (PET) scan and a computed tomography 
(CT) scan.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that LTACH services are medically 
necessary. The Plan denied your request. The Plan says that the coverage criteria has not been met. 
 
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 that the documentation does not support that the enrollee has the need for complex 
medical treatment in a LTACH. The enrollee has improved medically and can receive further care at the current 
acute care hospital or a lower level of care when deemed appropriate. 
 
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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says based on Medicare 
guidelines and the information we have about the enrollee's condition they do not meet all the requirements. 
 
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 from a nursing perspective, the enrollee received oral medications, had stable vital 
signs, and was treated for a urinary tract infection. The enrollee received physical and occupational therapy and 
was at supervision to contract guard assist level with functional mobility including gait to 75 feet. The enrollee 
required varying assist with activities of daily living skills. The enrollee does not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee 
does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a 
skilled professional therapist. Our reviewer also found the enrollee does not require daily skilled nursing and/or 
skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee requires more time for stabilization prior to transition 
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 enrollee was admitted with acute hypoxic respiratory failure in the setting of 
urosepsis. The record indicates that the enrollee continues to have acute medical issues including anemia and 
respiratory insufficiency and requires ongoing acute care services. The enrollee is receiving appropriate care at 
the present setting. The enrollee does not require services at the LTACH that are not available at the current 
facility where they are currently receiving care. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.