Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network referral for a second opinion. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be provided in the plan's network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 
 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
an out-of-network referral for a second opinion.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5211), a mandibular partial 
denture (D5212), and a resin-based composite (D2330 and D2391) provided by a participating provider on 
December 15, 2021. 
 
You asked the Plan to pay for a maxillary partial denture, a mandibular partial denture, and a resin-based 
composite. You say that you feel like this should all be covered. The Plan denied your request. The Plan says 
the rendered dental 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 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 pay for a 
maxillary partial denture (D5211), a mandibular partial denture (D5212), and a resin-based composite (D2330 
and D2391) provided by a participating provider on December 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the OneTouch Ultra test strip. 
 You asked the Plan to pre-approve the OneTouch Ultra test strip. You say that these specific test strips are 
medically necessary. The Plan denied your request. The Plan says there is no medical need for the non-
preferred test strips. 
 
The Plan follows Medicare rules. Medicare rules say that non-preferred products are subject to the coverage 
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 OneTouch Ultra test strip. Our 
reviewer says that the requested brand of test strip is not medically reasonable and necessary. Our physician 
reviewer found there is no reason given why this patient could not use the preferred brand instead of the brand 
being requested. If there is a reason why the preferred brad would not suffice, this should be stated. 
 
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 OneTouch Ultra test strip have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the OneTouch Ultra test strip.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutments (D6056) and implant supported 
porcelain/ceramic crowns (D6065). 
 
You asked the Plan to pre-approve prefabricated abutments and implant supported porcelain/ceramic crowns. 
You say that you are upset because the implants were started and now cannot be finished. You also say that you 
cannot eat properly and are having digestion issues. The Plan denied your request. The Plan says these services 
are not covered under your benefit plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
prefabricated abutments (D6056) and implant supported porcelain/ceramic crowns (D6065).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on August 4, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  The file shows that CPT code 88342 was billed with code 88189. We find that CPT code 88342 may be eligible 
for payment when billed with this code pair. The claim information does not show that CPT code 88342 was 
billed with a modifier suitable for payment. Because the primary procedure code, 88342, is not eligible for 
payment, the add-on code, 88341 is also not eligible for payment. 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 lab testing services provided on August 4, 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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 is receiving appropriate care at the present acute care hospital. 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 long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the oral exam (D0120), prophylaxis (D1110), complete series x-ray 
(D0210), scaling and root planing (D4342), and limited oral evaluation provided from May 5, 2021, to August 5, 2021. 
 
You asked the Plan to pay for the scaling and root planing on June 9, 2021. You say that you received services 
from this provider in 2020 that were paid. You say that you do not understand why they are not paying this 
year. The Plan denied your request. The Plan says that scaling and root planing is not listed as covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the file indicates that scaling and root planing is listed as a covered 
service. The Plan did not provide any documentation to substantiate that this service should not be covered. 
Therefore, we decided that the Plan has to pay for the oral exam (D0120), prophylaxis (D1110), complete 
series x-ray (D0210), scaling and root planing (D4342), and limited oral evaluation provided from May 5, 
2021, to August 5, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) and expandable 
controller and accessories (E2377, E2311, E2313). 
 
You asked the Plan to pre-approve a power seat elevation feature and expandable controller and accessories. 
You say that this equipment is medically necessary. The Plan denied your request. The Plan says the criteria for 
coverage have not been met. 
 
The Plan follows Medicare rules. 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. The 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 a power seat elevation feature and 
expandable controller and accessories. Our reviewer says that the requested expandable controller is not 
medically reasonable and necessary. Our physician reviewer found based on the medical records provided there 
is no documentation that the expandable controller, harness and electronic connection meet Medicare criteria 
for medically necessary. Provided records document that the enrollee has functional bilateral hands and fingers 
with no reported deviations or deformity, he has 3/5 bilateral upper extremity strength, and he is independent 
with eating thus indicating he has adequate upper extremity strength and function to operate the wheelchair's 
power options with their own switches. In addition, E2300 (seat elevator) is statutorily non-covered per 
Medicare rules. 
 
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 power seat elevation feature and expandable controller and accessories have 
not been met.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and complete 
series x-ray (D0210) provided on November 16, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were not happy with the initial dentist you 
saw after moving. You say that you found a new dentist as a result. You also say that you feel the first dentist 
should have identified the problem that you were having. The Plan denied your request. The Plan says the 
frequency limits for these services have been exceeded. 
 
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 and a comprehensive oral evaluation 
and complete series x-ray are covered once every 3 plan years, the frequency limits have been exceeded.  The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you 
received on September 16, 2021. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), and complete series x-ray (D0210) provided on November 16, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a cardioversion procedure (92960) 
performed on December 14, 2021. 
 
You asked the Plan to waive the copayment for the cardioversion procedure. You say that the services should 
be covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing 
applied correctly based on the services provided. 
 
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 $400 
copayment for Outpatient hospital services.  
 
 You have been asked to pay a $400 copayment for a cardioversion procedure. Cardioversion procedures fall 
within the Outpatient hospital services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
cardioversion procedure (92960) performed on December 14, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that the enrollee is too sick to drive to 
Vanderbilt by herself, and the enrollee needs transport of a motorized wheelchair and oxygen. The Plan denied 
your request. The Plan says you are requesting an additional 242 miles for a total of 292 miles and the 
enrollees benefit only allows 50 miles. The Plan also says the enrollee has exceeded her benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers up to 24 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Specifically, trips over 50 miles 
are not covered. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation mileage (A0170).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trodelvy (sacituzumab govitecan-hziy). 
 
You asked the Plan to pre-approve the drug. You say that this is needed to treat breast cancer. The Plan denied 
your request. The Plan says the tests do not show ER-positive protein. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found Trodelvy (sacituzumab 
govitecan-hziy) is FDA approved for the treatment of metastatic triple negative breast cancer. On most recent 
biopsy this patient's tumor was ER+ at 15% and the patient received treatment for ER+ breast cancer 
(anastrozole, Ibrance, Faslodex). The service is not reasonable or medically necessary. 
 
 
 
 
 
 
 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Trodelvy (sacituzumab govitecan-hziy).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for the extraction (D7140), tooth pin 
retention (D2951 x 2) and recement or rebond of crown (D2920) provided from October 28, 2021, to 
November 4, 2021. 
 
You asked the Plan to pay an additional amount for the dental services. You say that your appointment in 2020 
was cancelled. You say that in November 2021 you were having problems with your teeth. You say that 
because of the coronavirus pandemic and through no fault of your own, your plan paid $0 during 2020. You 
also say that you feel this bill should be covered as this coronavirus has been hard on everyone. The Plan 
denied your request. The Plan says the annual maximum benefit has 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, the annual maximum benefit has been 
exhausted. The record shows that the Plan paid $159 for services received on March 25, 2021, $119 for 
services received on October 20, 2021, $173 for services received on October 25, 2021, $49 towards the 
extraction received on October 28, 2021. $159 + $119 + $173 + $49 = $500. Therefore, we decided that the 
Plan does not have to pay an additional amount for the extraction (D7140), tooth pin retention (D2951 x 2) and 
recement or rebond of crown (D2920) provided from October 28, 2021, to November 4, 2021.
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 receiving appropriate inpatient acute care and does not 
require transfer to a Long-Term Acute Care Hospital (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 there is no documentation provided indicating medical necessity for admission to a 
LTACH. The enrollee is receiving appropriate care at the present acutre care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he/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 pay for the crown (D2740) and core buildup, including any pins 
when required (D2950) provided on December 22, 2021. 
You asked the Plan to pay for the crown and core buildup. You say that you cannot afford to pay for these 
services. The Plan denied your request. The Plan says these services are not covered under your plan. The Plan 
also says that you were on the $500 max benefit plan for dental coverage which only covers diagnostic and 
preventive services. 
 
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 pay for the crown 
(D2740) and core buildup, including any pins when required (D2950) provided on December 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ankle control orthosis (L4350) provided on 
September 5, 2021. 
 
You asked the Plan to waive the copayment for the ankle control orthosis. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the coinsurance applied 
correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Durable medical equipment (DME) and related supplies.  
 
 
  You have been asked to pay a 20% coinsurance for the ankle control orthosis (allowed is $83.90 x 20% = 
$16.78). Ankle control orthosis falls within the Durable medical equipment (DME) and related supplies benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for ankle control orthosis (L4350) provided on 
September 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular denture (D5120) to be provided 
by a participating provider. 
 
You asked the Plan to pre-approve a complete mandibular denture. You say that you lost your lower denture. 
You say that you need a replacement because you have soars in your mouth and cannot eat. The Plan denied 
your request. The Plan says the benefit limit for D5120 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 covers one complete 
mandibular denture every five years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D5120 was provided on April 
18, 2019. Based on this information, we decided that the Plan's rules for coverage of a complete mandibular 
denture have already been met. Therefore, we decided that the Plan does not have to pre-approve a complete 
mandibular denture (D5120) to be provided by a participating provider.