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

 
We decided that the Plan does not have to pre-approve consultation and treatment with a prosthodontist. 
 
You asked the Plan to pre-approve dental service. You say that you have 2 loose teeth that cause trouble when 
eating. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because services performed by a prosthodontist are not covered by the Plan's 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 pre-approve 
consultation and treatment with a prosthodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial dental exam (code D0150) you received on 
October 26, 2021. 
 
You asked the Plan to pay for the initial dental exam. You say that you saw the dentist for a crown that went 
wrong.  You say that you now need a dental implant and you do not have enough money to pay for dental care. 
The Plan denied your request. The Plan says initial dental exams (code D0150) are only covered once every 
thirty six months, and you already received one of these on April 13, 2021.  Therefore, you were not eligible 
for another one on the date of service in question. All of the other dental services from that date of service have 
been approved. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the initial 
dental exam (code D0150) you received on October 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a new Group 2 power wheelchair (PWC). 
 
You asked the Plan to pre-approve the new PWC. You say that the enrollee requires this PWC as physical 
therapy will not be likely to allow him to walk again. The Plan denied your request. The Plan says the enrollee 
received a new PWC in July 2021. There is no evidence that this PWC no meets the enrollee's needs. 
 
The Plan must follow Medicare rules. Medicare rules say that replacement DME is covered in the event of 
irreparable damage. However, replacement for irreparable wear is not covered within the 5-year reasonable 
useful lifetime (RUL). 
 
In this case, the enrollee was provided with a similar PWC less than one year ago. There is no evidence that the 
PWC was irreparably damaged. Replacement is not covered in this situation. Therefore, we decided that the 
Plan does not have to pre-approve a new Group 2 power wheelchair (PWC).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313), 
power-seat elevation feature (E2300) and elbow support accessory (K0108). 
 
You asked the Plan to pre-approve the requested power wheelchair accessories. You say that these items are 
medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met 
for these items. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Medicare 
rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered 
because they are not primarily medical in nature. Medicare rules say that an expandable controller is subject to 
the criteria listed 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 the requested power wheelchair 
accessories. Our reviewer says that the documentation does not support the request for the expandable 
controller. Our physician reviewer found in this case, the member has a neurologic disorder with functional 
deficits. She meets criteria for use of a power mobility device. The requested accessories are not medically 
necessary as he does have use of his hands and can operate and control the power options using the switches 
that are included in the basic wheelchair.  
 
Regarding the power seat elevation feature, this item according to Medicare rules is statutorily non-covered as 
not medical in nature. Meanwhile, the request for elbow support coded as K0108 is miscoded. There is a more 
appropriate code that should be used for the requested items. 
 
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 requested power wheelchair accessories have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an expandable controller (E2311, E2377, E2313), power-
seat elevation feature (E2300) and elbow support accessory (K0108).
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. The Plan denied your request. The Plan says 
admission to an LTACH is not to be used as an alternative to completion of the full course of treatment in the 
referring hospital. 
 
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 you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis.

You asked the Plan to pre-approve Restasis. You say that the requested drug is necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

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 Restasis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received on June 25, 2020. 
 
You asked the Plan to pay for the dental services. You say that no one ever told you about the filing time limit, 
so this should be waived. The Plan denied your request. The Plan says you did not file this claim timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. Your Evidence of Coverage also 
explicitly advises you that you must file claims within 12 months. 
 
The record shows that a claim for the dental services was not filed until December 21, 2021. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for dental services you received on June 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that enrollee is not on insulin, but his glucose levels 
are unknown due to right arm amputation. The Plan denied your request. The Plan says the criteria for coverage 
are not 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 treat with insulin three or more times per day or use an insulin pump. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 10, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 10, 
2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with 
concurrently acquired computed tomography (CT) scan of the skull base to mid-thigh. 
 
You asked the Plan to pre-approve a PET CT scan. You say that this procedure is medically reasonable and 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare will continue to non-cover initial anti-
tumor treatment strategy in Medicare beneficiaries who have adenocarcinoma of the prostate. Therefore, we 
decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently 
acquired computed tomography (CT) scan of the skull base to mid-thigh.  Therefore, we decided that the Plan 
does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed 
tomography (CT) scan of the skull base to mid-thigh.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two resin-based composites (D2331) provided on July 
13, 2021, and the intraoral periapical x-rays (codes D0230 and D0220) provided on October 12, 2021. 
 
You asked the Plan to pay for the composites and intraoral x-rays. You say that these claims were denied in 
error. The Plan denied your request. The Plan says while other dental services provided to this enrollee were 
covered, these specific services are not covered under the enrollee's supplemental dental benefit. 
 
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. This benefit includes coverage 
only of those dental services and codes listed in the 2021 Deluxe Combo Dental Benefits Chart. Resin-based 
composites (D2331) and intraoral periapical x-rays (codes D0230 and D0220) are not listed on this chart.   
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the two 
resin-based composites (D2331) provided on July 13, 2021, and the intraoral periapical x-rays (codes D0230 
and D0220) provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve outpatient visits at the in-network benefit level with an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve outpatient visits at the in-network benefit level. You say that you would like 
to continue to see this OON provider because you are hesitant to see a new provider. The Plan denied your 
request. The Plan says the available medical information does not support the need for an authorization to a 
non-plan 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve 
outpatient visits at the in-network benefit level with an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 4, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from May 4, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from May 4, 
2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of May 4, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond May 4, 2022, as you were not a danger to yourself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from May 4, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from May 4, 2022, 
forward.
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 admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that you continue to receive acute care services, and these have not been denied. The 
medical record does not indicate that you require services that you are not currently receiving but that would be 
available at the LTACH 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 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a revision/repeat bariatric surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says that there is no technical complication associated with the initial sleeve gastrectomy 
which requires surgical intervention to correct. 
 
The Plan must follow Medicare rules. Medicare rules say that services are covered 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 surgery. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found you had an unusually poor response to laparoscopic vertical sleeve gastrectomy (LVSP). You have a 
functional complication of the surgery with gastro-esophageal reflux disease (GERD) and narrowing or 
stricture of the incisura. You continue to meet all of the primary criteria for bariatric surgery, with severely 
elevated BMI of 62 kg/m2, and multiple obesity-related comorbid related conditions. You will continue to 
benefit from both treatment of GERD/stricture and additional weight loss with conversion to gastric bypass, 
which is a standard treatment for post-sleeve gastrectomy GERD and technical complications, such as 
narrow/stricture. 
 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 surgery have been met. Therefore, we decided that the Plan has to pre-
approve a revision/repeat bariatric surgery.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the health club membership (S9970) provided from January 
1, 2021, through April 1, 2021. 
 
You asked the Plan to pay for the health club membership. You say that you would like to be reimbursed for 
these services. The Plan denied your request. The Plan says there is insufficient proof of payment to process 
this request. 
 
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 health club membership have been met. Specifically, there is insufficient documentation to provide proof of payment. Therefore, we decided that 
the Plan does not have to pay for the health club membership (S9970) provided from January 1, 2021, through 
April 1, 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 it is your professional opinion that the enrollee will 
receive the appropriate level of care in the IRF. The Plan denied your request. The Plan says the denial of 
authorization for IRF care is correct. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically stable and does not need rehabilitation physician supervision 3 times per week for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. While the enrollee may benefit from physical and occupational therapy, the enrollee's 
rehabilitation needs can be safely met at a lower intensity setting such as a 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two alveoloplasties not in conjunction with extractions 
(D7320 x2) and deep sedation/general anesthesia (D9222 and D9223). 
 
You asked the Plan to pre-approve the alveoloplasties and deep sedation/general anesthesia. The Plan denied 
your request. The Plan says these services are not covered 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, alveoloplasty not in conjunction with 
extractions (D7320) is not among those covered under this benefit. The deep sedation/general anesthesia 
(D9222 and D9223) is not covered because the main procedure is not a covered benefit. Therefore, we decided 
that the Plan does not have to pre-approve two alveoloplasties not in conjunction with extractions (D7320 x2) 
and deep sedation/general anesthesia (D9222 and D9223).