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

We decided that the Plan does not have to pre-approve an occlusal guard - full arch (D9944) provided by a 
participating provider. 
 
You asked the Plan to pre-approve an occlusal guard. You say that you grind your teeth and would like a guard. 
The Plan denied your request. The Plan says this is not a covered benefit. 
 
 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 under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
occlusal guard - full arch (D9944) provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prasugrel tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, 
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare 
Part D prescription drug benefits. 
 
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 prasugrel tablets.  
 Benefits for self-administered drug 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 a $25.00 Over-the Counter (OTC) benefit roll over. 
 
You asked the Plan to pre-approve a $25.00 Over-the Counter (OTC) benefit roll over. You say that you were 
unaware of your OTC benefit until a few weeks ago and you were unable to use the $25 benefit for the first 
three (3) quarters of the year. You say that you should get $75.00 back. The Plan denied your request. The Plan 
says quarterly allowances cannot be carried over to another quarter. Any quarterly allowance not used is 
forfeited at the end of each quarter. 
 
The contract with the Plan says quarterly allowances cannot be carried over to another quarter. 
 
We looked at the file and the Plan?s rules The file shows that quarterly allowances cannot be carried over to 
another quarter. Therefore, we decided that the Plan does not have to pre-approve a $25.00 Over-the Counter 
(OTC) benefit roll over.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed for the enrollee. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that a total electric hospital bed is 
medically necessary. The Plan denied your request. The Plan says a total electric hospital bed is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve stereotactic body radiation therapy for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no current research that shows that this type of cancer responds better to the 
requested treatment over the standard. 
 
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 the therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found stereotactic body radiotherapy (SBRT), delivering high fractional doses in 2-5 fractions is an established 
approach for the treatment of discrete lesions from cancer. There is abundant data on the use of SBRT for Stage 
I and II (node negative) non-small cell lung cancer (NSCLC). It may be that the denial is based upon the 
preliminary diagnosis of possible N1-N2 disease for which SBRT would not be standard of care. The enrollee 
has undergone a work-up to rule out nodal or distant metastases, and this request falls within the accepted 
standards of medical practice. 
 
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 therapy have been met. Therefore, we decided that the Plan has to pre-
approve stereotactic body radiation therapy for the enrollee.  
 
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 pre-approve caries risk assessment (D0601). 
 
You asked the Plan to pre-approve the dental service. You say that this service is necessary. The Plan denied 
your request. The Plan says caries risk assessment is not listed as a covered service. 
 
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, caries risk assessment is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve caries risk 
assessment (D0601).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87150) provided on September 2, 2020. 
 
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied 
your request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).   
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent 
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (87150) provided on September 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular screening testing provided on 
April 21, 2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the testing 
was not approved by the ordering provider. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. We looked at the file and the rules. The records provided do not indicate the enrollee's provider ordered the 
testing for a specific medical problem. It appears that the services were offered during an unsolicited outreach 
telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating 
physician. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular 
screening testing provided on April 21, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
 
 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 you do not require treatment by multiple therapies, including either physical therapy 
or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the radium ra 223 dichloride (A9606). 
 
You asked the Plan to pre-approve the radium ra 223 dichloride. You say that the drug is medically necessary. 
The Plan denied your request. The Plan says the drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 the radium ra 223 dichloride. Our 
reviewer says that the drug is not medically necessary. Our physician reviewer found the drug is not FDA 
approved for the enrollee's diagnosis and it's use is not supported by any of the major drug compendia. 
 
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 radium ra 223 dichloride have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the radium ra 223 dichloride (A9606).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulmonary gene testing provided on October 17, 2020. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. If a single procedure is performed, only one HCPCS/CPT code with one 
unit of service may be reported for the procedure. Based on this information, we decided that Medicare rules 
for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay 
for the pulmonary gene testing provided on October 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with power tilt and 
power recline options. 
 
You asked the Plan to pre-approve the group 3 power wheelchair with power tilt and power recline. You say 
that the extended features are necessary. The Plan denied your request. The Plan says the documentation does 
not show that the enrollee meets coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that to qualify for a group 3 power wheelchair with 
Multiple Power Options, there must be medical need for a ventilator or for two power options: power tilt and 
power recline. 
 
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 group 3 power wheelchair with 
power tilt and power recline. Our reviewer says that the power tilt and power recline system are not medically 
necessary. Our physician reviewer found the enrollee does not meet criteria for power tilt and power recline 
system as there was no report of significant spasticity, ulcers, or need for self-catheterization and she has 
reasonable upper strength which doesn't support the above features.  
 
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 group 3 power wheelchair with power tilt and power recline have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with 
power tilt and power recline options.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (K0554) 
with supplies (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre with supplies. You say that the requested items are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for continuous glucose 
monitors have not been met. 
 
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 a 
Freestyle Libre with supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve a Freestyle Libre continuous glucose monitor (K0554) with supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to preapprove the CGM. You say that you require the CGM because you struggle to 
remember to check your blood sugar without a monitor. The Plan denied your request. The Plan says you do 
not meet the coverage criteria. 
 
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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-
adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to preapprove a therapeutic continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the enrollee is not required to discharge elsewhere to receive ongoing acute 
level care. 
 
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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where she is currently receiving 
care. There are no services available at the LTACH that the enrollee requires that are not available at the health 
care setting being offered by the health plan. 
 The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve hearing aids. You say that the patient is in need of another pair of hearing 
aids as he needs them for his activities of daily living. You say the patient is noted to be severely hearing 
impaired as noted on audiology. The Plan denied your request. The Plan says the enrollee has exhausted the 
2021 hearing aid benefit. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan?s coverage rules apply in this case. The Plan pays for 
hearing aids only 1 per ear, per year. 
 
We looked at the file and the Plan's rules. The file shows that the enrollee exhausted the hearing aid benefit on 
January 21, 2021. Based on this information, we decided that the Plan's rules for coverage of hearing aids have 
not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthosis (L1833) on May 8, 2021. 
 
You asked the Plan to pay for the knee orthosis. You say that the enrollee requires the knee brace for weakness 
in his knees. The Plan denied your request. The Plan says the documentation did not show that the enrollee met 
coverage criteria. 
 
The Plan follows Medicare rules. Medicare rules say that a knee brace (1833) will be considered medically 
necessary if the beneficiary has had recent injury to or a surgical procedure on the knee(s).  The rules also say 
that knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is 
ambulatory and has knee instability due to a condition specified in the ICD-10 Codes that Support Medical Necessity Group 4 Codes section. Knee instability must be documented by examination of the beneficiary with 
objective description of joint laxity. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the knee orthosis. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found has had recent injury to or a surgical 
procedure on the knee(s). While there is documentation of joint laxity, it is not objective. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does 
not have to pay for the knee orthosis (L1833) on May 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator (E1392). 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that the requested item is a necessity for 
your care. The Plan denied your request. The Plan says rules for out-of-area care have not been met. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, the Plan contract, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oxygen concentrator have not been met. Specifically, the requested oxygen 
concentrator has been ordered for delivery to a location outside the Plan's service area. Therefore, we decided 
that the Plan does not have to pre-approve an oxygen concentrator (E1392).