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

 
We decided that the Plan does not have to pre-approve use of a portable ventilator. 
 
You asked the Plan to pre-approve portable ventilator. You say that a bilevel positive airway pressure (BiPAP) 
device with average volume assured pressure support (AVAPS) mode was ruled out as this does not provide 
battery backup and is not portable in and out of the home. The Plan denied your request. The Plan says the 
denial of authorization for this device is correct, because a ventilator is not covered for this purpose and your 
needs can be met by a BiPAP device with AVAPS mode. 
 
The Plan must follow Medicare rules. Medicare rules say that a ventilator is not covered when used to provide 
continuous or bilevel positive airway pressure (CPAP or BiPAP) therapy, regardless of the underlying medical 
condition.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-
approve use of a portable ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer (D6549). 
 
You asked the Plan to pre-approve the retainer. You say that the enrollee has large lingual torus which make 
any removable appliances not an option. The Plan denied your request. The Plan says this service is not 
covered under the enrollee's 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 a 
retainer (D6549).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the arm for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary based on pain in the left upper arm. The Plan denied your request. The Plan says that an alternative would a computed tomography (CT) scan or x-ray.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is medically reasonable and necessary. Our physician reviewer found the enrollee continues to have significant left am pain greater than 8 weeks following 2 vaccinations. Left arm ultrasound was done 3/18/22 and was negative. There is no superficial bruising. Due to the persistent left arm pain after penetrating trauma in the face of a negative ultrasound, MRI is the next procedure of choice. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the arm 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine (J0571). 
 
You asked the Plan to pre-approve Buprenorphine. You say that alternative pain regimens have proven 
ineffective. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition by 
their Medicare Part B plan. 
 
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 Buprenorphine (J0571).  
 
Benefits for Buprenorphine 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 implant placement (D6010 x 2), and abutment 
supported crown (D6058 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that your dentures do not stick. You say that 
this is the case even if there is glue applied. You also say that you cannot eat because of this. The Plan denied 
your request. The Plan says dental implants and all associated services are excluded from coverage. 
 
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 implant placements and 
abutment supported crowns are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve implant placement (D6010 x 2), and abutment supported crown (D6058 x 2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six surgical placements of implant bodies: endosteal 
implants (D6010 x6), six abutment supported porcelain/ceramic crowns (D6058 x6), six abutment supported 
porcelain fused to metal crowns (D6060 x6), and a sinus augmentation with bone or bone substitutes (D7951). 
 
You asked the Plan to pre-approve the endosteal implants, abutment supported porcelain/ceramic crowns, 
abutment supported porcelain fused to metal crowns, and sinus augmentation with bone or bone substitutes. 
You say that you need these services to be approved for coverage. 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 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 six 
surgical placements of implant bodies: endosteal implants (D6010 x6), six abutment supported 
porcelain/ceramic crowns (D6058 x6), six abutment supported porcelain fused to metal crowns (D6060 x6), 
and a sinus augmentation with bone or bone substitutes (D7951).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six endosteal implants (D6010 x6) and three custom 
fabricated abutments (D6057 x3). 
 
You asked the Plan to pre-approve the endosteal implants and custom fabricated abutments. You say that you 
need the implants and believe these services should be covered. 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 six 
endosteal implants (D6010 x6) and three custom fabricated abutments (D6057 x3).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a digital breast tomosynthesis and a breast 
ultrasound provided on December 28, 2021. 
 
You asked the Plan to waive the copayment for a breast tomosynthesis and an ultrasound. You say that you do 
not understand why you owe $125. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $125 
copayment for outpatient diagnostic radiological services.  
The record shows these services were approved, and you have a cost sharing amount. You have been asked to 
pay the allowed amount of $24.33, which is less than the $125 copayment for a breast tomosynthesis. You have 
also been asked to pay the allowed amount of $13.49, which is less than the $125 copayment for an ultrasound. 
A breast tomosynthesis and an ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services 
and 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 a digital breast 
tomosynthesis and a breast ultrasound provided on December 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain/ceramic crowns (D2740) and core buildups 
(D2950) for teeth #30 and #31. 
 
You asked the Plan to pre-approve crowns and core buildups. You say that your teeth are cracking and 
breaking, and these services are medically necessary. The Plan denied your request. The Plan says the 
requested crowns are not medically necessary; your records do not show that over 50% of these teeth are lost 
due to a very large defective restoration. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers crowns and 
core buildups when the services are medically necessary and reasonable.  
 
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 crowns and core buildups. Our reviewer 
says that the documentation provided does not meet the criteria for coverage of core buildups (D2950) and 
crown restorations (D2740) for teeth #'s 30 and 31. Our physician reviewer found the documentation does not 
indicate that these teeth have significant coronal breakdown due to caries or fracture which would require 
crown restorations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of crowns and core buildups have not been met. Therefore, we decided that the 
Plan does not have to pre-approve porcelain/ceramic crowns (D2740) and core buildups (D2950) for teeth #30 
and #31.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMS device was approved 
by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary 
artery to allow measurement of pulmonary artery pressure in the management of patients with congestive heart 
failure (CHF). Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. 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 CardioMEMs Heart Failure system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 these services. Our reviewer says that 
the criteria for coverage are not met. Our physician reviewer found the records show you have a personal 
mobility deficit that impairs participation in mobility-related activities of daily living (MRADLs) in the home. 
The records do not show that the mobility deficit cannot be helped by the use of a manual wheelchair. The 
power scooter is therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fourth crown (D2740) and gingivectomy or 
gingivoplasty (D4210). 
 
You asked the Plan to pre-approve the crown and gingivectomy/gingivoplasty. You say that these services are 
medically necessary, and you believed you had a higher coverage limit. The Plan denied your request. The Plan 
says you have already been approved for three crowns, and the request for a fourth crown and gingivectomy 
and gingivoplasty will exceed your $1,500 coverage limit for comprehensive dental care. 
 
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. Your contract with the Plan 
states that your dental benefit covers a maximum of $1,500 per year for covered comprehensive dental 
services. 
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services are requested in 
excess of the $1,500 coverage limit for 2022. The record shows that you have been approved for three crowns 
this year, and the Plan has provided documentation to support that these services will use the entirety of your 
$1,500 annual benefit. Therefore, we decided that the Plan does not have to pre-approve a fourth crown 
(D2740) and gingivectomy or gingivoplasty (D4210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant 
(D6010). 
 
You asked the Plan to pre-approve the endosteal implant. You say that you need this service approved for 
medical reasons. The Plan denied your request. The Plan says this service is 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 a 
surgical placement of implant body: endosteal implant (D6010).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transurethral resection of the prostate (TURP). 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found you have urge incontinence and 
incomplete bladder emptying. You had a TURP procedure three years ago. Imaging shows no bladder outlet 
obstruction by the prostate. The records do not support that the requested TURP is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transurethral resection of the prostate (TURP).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Feraheme (Q0138). 
 
You asked the Plan to pre-approve Feraheme. The Plan denied your request. The Plan says that this request 
does not meet the Plan's Part B step therapy criteria for the requested drug. 
 
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 Independent Review Entity (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. The Plan did not provide a copy of the applicable 2022 Evidence of Coverage 
for this case. We asked for this document, but it was not provided to us. Without this information we cannot 
determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been 
adequately notified of the Plan's coverage rules and benefits. Consequently, the Plan has not substantiated their 
denial of payment in this case. Therefore, we decided that the Plan has to pre-approve Feraheme (Q0138).  
 
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 ten (10) additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that the additional 
routine transportation trips are necessary. The Plan denied your request. The Plan says the request exceeds the 
benefit. 
 
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.  
 
We looked at your request, the records in the case file, and the rules. You have exhausted all allowed trips, 
there are no trips remaining. Your request for 10 additional trips exceeds the benefit limit for these services. The 2022 plan benefits say you have an additional benefit for routine transportation for up to twenty-four (24) 
one way transportation trips per calendar year, limited to ground transportation only to destinations within fifty 
(50) miles of the pickup location. Therefore, we decided that the Plan does not have to pre-approve ten (10) 
additional routine transportation trips.
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 enrollee requires IRF care to help decrease 
further functional decline and reduce risk for admission to an acute care hospital. The Plan denied your request. 
The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF admission. 
 
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 that in this case, the complexity of the enrollees nursing, medical and rehabilitation 
needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. The enrollee does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that 
this individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. The enrollee continues to have a need for skilled therapy with ongoing safety concerns and 
a potential for functional improvement however, the documentation doesnt support that he would meet criteria 
for admission to an acute inpatient rehabilitation facility. There is no indication that the enrollee would require 
skilled rehabilitation in an IRF, participating in rehabilitation services 15 hours a week, under the supervision 
of a physician with at least 3 visits weekly to regain or maintain his functional status. The enrollee can receive 
further services at a lower level of 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 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.