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

 
We decided that the Plan does not have to pre-approve a back brace to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a back brace. You say that you do not want to go to the in-network facility, 
they do not work well or help you. The Plan denied your request. The Plan says There was no preauthorization 
by a primary care provider (this is different than a referral) for an out-of-network (OON) provider or facility. 
 
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 
a back brace to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210 x10). 
 
You asked the Plan to pre-approve the extraction, erupted tooth requiring removal of bone and/or sectioning of 
tooth. You say that the enrollee is in need to have all teeth extracted due to an infection and is continuously on 
antibiotics. The Plan denied your request. The Plan says this service is not covered under the benefit package. 
 
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 an 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210 x10).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper and lower complete dentures (D5110, D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you want to file a prior authorization on 
her tooth extraction. The Plan denied your request. The Plan says your benefit for the requested item or service 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 26, 2021. 
Therefore, we decided that the Plan does not have to pre-approve the upper and lower complete dentures 
(D5110, D5120).
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 a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for the requested CGM. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an outpatient mental health visit provided on July 11, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for an outpatient mental health visit. You say that prior authorization is not required 
for mental health services. The Plan denied your request. The Plan says the services were obtained by an out-
of-network (OON) provider and there is no authorization on file for the services. 
 
 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an outpatient mental health visit provided on July 
11, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on July 21, 
2022, to July 26, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you disagree with the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $150 
copayment per day for days 1-6 for inpatient hospital care.  
 
You have been asked to pay a $150 copayment per day for days 1-6 for inpatient hospital care. The total 
amount you are being asked to pay is $750 ($150 x 5days = $750). This item/service falls within the inpatient 
hospital care 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 inpatient hospital care 
provided on July 21, 2022, to July 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor (CGM). You say that you are 
now on insulin and would like the Plan to reconsider the approval of the CGM. The Plan denied your request. 
The Plan says you do not require insulin three or more times daily. 
 
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 you do not use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the 
therapeutic continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93355 billed for date of service June 2, 2022. 
 
You asked the Plan to pay for procedure code 93355. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says payment for code 93355 is bundled into 
payment for code 00560. 
 
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 93355 
is a column II code to column I code 00560 with a modifier indicator of 0. The column II code is therefore not payable. 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 93355 billed for date of service June 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment every 4 weeks with Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio every 4 weeks. You say that the requested treatment regimen is a 
medical necessity for you. The Plan denied your request. The Plan says the requested drug has been prescribed 
for an off-label, not medically accepted use. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Entyvio every 4 weeks. Our reviewer 
says that the requested treatment regimen is not medically reasonable and necessary in this case. Our physician 
reviewer found that the FDA-approved package information "allows for a treatment regimen of every 8 weeks 
after the loading loses." The requested use of Entyvio is not FDA-approved for your diagnosis. The use is not 
supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved 
medical journal. 
 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio every 4 weeks have not been met. Therefore, we decided that the Plan 
does not have to pre-approve treatment every 4 weeks with Entyvio (J3380).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve image guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve image guided radiation therapy. You say that this service is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
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 image guided radiation therapy have 
been met. No clinical records were submitted to the health plan to support this request. Therefore, we decided 
that the Plan does not have to pre-approve image guided radiation therapy (G6001).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pay for the home health services provided from June 3, 2022, to June 13, 2022. 
 
You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed. 
 
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. Medicare rules say that the HHA notifies Medicare systems via submission of an NOA. Only one 
NOA is required for any series of HH periods of care beginning with admission to home care and ending with 
discharge. 
 
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 case record indicates that the episode of care at issue is not the 
initial episode of care and does not require submission of an NOA specific to the episode of care. Therefore, we 
decided that the Plan has to pay for the home health services provided from June 3, 2022, to June 13, 2022.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee generally must receive care from a network provider. In most 
cases, care the enrollee receives from an out-of-network provider (a provider who is not part of the plans 
network) will not be covered. 
 
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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth - completely bony tooth #'s 
1, 16, 17, and 32 (D7240). 
 
You asked the Plan to pre-approve the removal of impacted tooth - completely bony tooth #'s 1, 16, 17, and 32. 
You say that you need your teeth extracted because of the pain it is causing you. The Plan denied your request. 
The Plan says this service is not covered under the benefit package. 
 
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 
removal of impacted tooth - completely bony tooth #'s 1, 16, 17, and 32 (D7240).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #29 (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that the patient tried to have a crown fixed at 
the previous dentist but the business had closed and was unable to find where they doctor went. The Plan 
denied your request. The Plan says the benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the benefit for the requested item or service was exhausted on date of service January 28, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #29 
(D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with codes A6530 and 
A6533. 
 
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings are 
medically necessary. The Plan denied your request. The Plan says the requested items are not a Medicare 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 and 
A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
  Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with codes A6530 and A6533.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from July 5, 2022, to 
August 3, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says the claim has not been billed 
with the correct admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from July 5, 2022, to August 
3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a mandibular denture (D5120) provided on 
October 5, 2022. 
 
You asked the Plan to waive the copayment for the dental services. You say that the services should be covered 
as you disagree with the denial. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
  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.    
 
You have been asked to pay a 50% coinsurance for dentures. This item/service falls within the dental 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 mandibular denture (D5120) 
provided on October 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Modafinil tablets. 
 
You asked the Plan to pre-approve Modafinil tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Modafinil tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
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 Modafinil tablets.  
 
Benefits for Modafinil tablets 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair, bathtub rails, and transfer tub rail 
attachment. 
 
You asked the Plan to pre-approve a shower chair, bathtub rails, and transfer tub rail attachment.. You say that 
the requested items are medically necessary for you. The Plan denied your request. The Plan says these items 
are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs and grab bars are not covered 
because they are not primarily medical in nature.  
 
  While a shower chair and grab bars may be appropriate in this case, neither the Plan nor Medicare offers 
coverage of these items. Therefore, we decided that the Plan does not have to pre-approve a shower chair, 
bathtub rails, and transfer tub rail attachment.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage for routine transportation miles. 
 
You asked the Plan to pre-approve the additional miles. You say that you need assistance with transportation  
to an appointment which is 92 miles away. The Plan denied your request. The Plan says the service is a covered 
benefit, but exceeds the limit listed by the Plan. 
 
 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 a maximum of 75 miles per one-way trip.  
 
We looked at your request, the records in the case file, and the rules. You are requesting an additional 17 miles 
for a total of 92 miles. Based on this information, we decided that you have exhausted the Plan maximum 
benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 
additional routine transportation miles.