Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Favorable

 
We decided that the Plan has to pre-approve nine additional home health physical therapy visits. 
 
You asked the Plan to pre-approve home health services. You say that you are requesting reconsideration of the 
denial for additional home health services. The Plan denied your request. The Plan says that the services are not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are medically reasonable and necessary. Our physician reviewer found that the enrollee 
has improved in terms of her bed mobility, transfers, and ability to ambulate, but continues to require the use of 
continuous passive range of motion device and has reduced range of motion at the left knee joint. Continued 
home health physical therapy is important in maximizing knee range of motion after knee arthroplasty to 
prevent contracture and reduced mobility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have been met. Therefore, we decided that the Plan has to 
pre-approve nine additional home health physical therapy visits.  
 
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 guided tissue regeneration, endosteal implant, 
alveoloplasty, and treatment of a root canal obstruction (D6014, D4266, D6010, D7320). 
 
You asked the Plan to pre-approve 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 services denied correctly as they do 
not fall within your 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 
guided tissue regeneration, endosteal implant, alveoloplasty, and treatment of a root canal obstruction (D6014, 
D4266, D6010, D7320).
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 this item. You say that you are requesting a reconsideration of the Plan's 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a recliner chair. 
 
You asked the Plan to pre-approve a recliner chair. You say that the item is necessary. The Plan denied your 
request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a recliner chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tissue biopsy provided on September 20, 2022. 
 
You asked the Plan to pay for the biopsy. You say that you should not be responsible to pay these charges. The 
Plan denied your request. The Plan says a tissue biopsy is not covered by your 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a tissue 
biopsy provided on September 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on March 12, 2022. 
 
You asked the Plan to pay for office visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says that unauthorized, out-of-network care is not 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
March 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on December 02, 2022. 
 
You asked the Plan to pay for a home visit. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
December 02, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a urology visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a urology visit. You say that you want this covered, as you have seen this 
provider years ago and want to see them again. The Plan denied your request. The Plan says there are multiple 
providers who are in-network, and in close proximity to your residence. 
 
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 urology visit to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve an acute inpatient mental health admission. 
 
You asked the Plan to pre-approve this service. You say that an acute inpatient mental health admission is 
medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not 
meet criteria for coverage of the requested service. 
 
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 this service. Our reviewer says that the 
requested service is medically necessary. Our physician reviewer found that the enrollee was involuntarily 
admitted for an acute inpatient psychiatric hospitalization on January 4, 2023 with Schizophrenia Spectrum 
Disorder. Based upon the review of the records provided, it was expected that this enrollee would improve in a 
reasonable period of time although she did not have dangerousness to self or others and was not showing any 
auditory/visual hallucinations or any aggressive behaviors. It did appear medically necessary and reasonable to 
have psychiatric care provided at the acute inpatient level of care rather than a lower level of care although she 
did not have dangerousness to self or others. The health plans denial of inpatient psychiatric services appears 
inappropriate. This enrollee does appear to require an inpatient mental health treatment program as she was not 
a danger to herself or others and was cooperative with care without any aggressive behaviors. It does appear 
that active treatment was taking place. It does appear that the services are reasonably expected to improve the 
enrollees condition or are for the purpose of a diagnosis. It does appear that the records were supervised and 
evaluated by a physician. Based upon the review of the records provided, this enrollee does meet criteria for 
acute inpatient mental health treatment as she was not shown to be a danger to herself or others. She did not 
have auditory or visual hallucinations and did have active treatment. 
 
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 been met. Therefore, we decided that the Plan has to pre-
approve an acute inpatient mental health admission.  
 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 cone beam CT capture and interpretation with limited field 
of view  less than one whole jaw (D0364), suture of recent small wounds up 5 cm (D7910), therapeutic 
parenteral drug, single administration (D9610), deep sedation/general anesthesia  first 15 minutes (D9222), 
deep sedation/general anesthesia  each subsequent 15-minute increment (D9223) and consultation - diagnostic 
service provided by dentist or physician other than requesting dentist or physician (D9310) provided on 
September 1, 2022, and September 2, 2022. 
 
You asked the Plan to pay for dental services. You say that the services received should be paid in full by your 
insurance. The Plan denied your request. The Plan says these services are not covered under your 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. Cone beam CT capture and 
interpretation with limited field of view  less than one whole jaw (D0364), suture of recent small wounds up 5 
cm (D7910), therapeutic parenteral drug, single administration (D9610), deep sedation/general anesthesia  
first 15 minutes (D9222), deep sedation/general anesthesia  each subsequent 15-minute increment (D9223) 
and consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) are not covered under the Plans dental benefits. 
 
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 cone 
beam CT capture and interpretation with limited field of view  less than one whole jaw (D0364), suture of 
recent small wounds up 5 cm (D7910), therapeutic parenteral drug, single administration (D9610), deep 
sedation/general anesthesia  first 15 minutes (D9222), deep sedation/general anesthesia  each subsequent 15-
minute increment (D9223) and consultation - diagnostic service provided by dentist or physician other than 
requesting dentist or physician (D9310) provided on September 1, 2022, and September 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) for tooth #21 provided on December 15, 
2022. 
 
You asked the Plan to pay for the dental service. You say that you only had 1 crown for the year of 2022, and it 
should be covered. 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 the Plan paid for 2 resin-based composites (D2330 and D2331) on February 8, 2022; therefore, your 
benefit for the requested item or service was exhausted on the date of service of February 8, 2022. Therefore, 
we decided that the Plan does not have to pay for a crown (D2740) for tooth #21 provided on December 15, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an interim partial denture (D5820), and diagnostic service 
consultation (D9310), provided on August 10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you never had to pay for these services before. 
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 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 an interim 
partial denture (D5820), and diagnostic service consultation (D9310), provided on August 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials (D4265), guided tissue regeneration 
(D4266), and bone replacement graft (D7953) for tooth #30 
 
You asked the Plan to pre-approve the dental services. You say that per your coverage the requested dental 
services should be covered, and it is medically necessary for you to get them done. The Plan denied your 
request. The Plan says the denial of authorization for these services is correct, because the biologic materials, 
guided tissue regeneration, and bone replacement graft are not covered by the 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 
biologic materials (D4265), guided tissue regeneration (D4266), and bone replacement graft (D7953) for tooth 
#30
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment 
supported to a crown (D6058) for tooth #30. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are necessary 
to prevent your implants from being damaged. The Plan denied your request. The Plan says your benefit for the 
requested items or services 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 Plan has authorized the maximum implant services on February 18, 2023; therefore, your benefit for 
the requested items or services was exhausted on the date of approval of February 18, 2023. Therefore, we 
decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment 
supported to a crown (D6058) for tooth #30.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Benlysta. 
 
You asked the Plan to pre-approve Benlysta. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 Benlysta. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
requested use of Benlysta is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of 
the major drug compendia or by clinical research that appears in a CMS-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 Benlysta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Benlysta.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgery provided on August 16, 2022, to August 30, 2022. 
 
You asked the Plan to pay for surgery. You say that you are requesting reconsideration. The Plan denied your 
request. The Plan says that unauthorized, out-of-network care is not 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for surgery provided on 
August 16, 2022, to August 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that 2023 The Plan denied your request. The Plan says 
the enrollee must receive their care from a network provider (for more information about this, see Section 2 in 
Chapter 3). 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. This means that the enrollee will have to pay the provider in 
full for the services furnished. 
 
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 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visits. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receive from an out-of-
network provider (a provider who is not part of the plan's 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 
office visits to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on December 21, 2022. 
 
You asked the Plan to pay for the wound care supplies. You say that the enrollee was in a nursing home and 
authorization should not be required. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the wound care supplies 
provided on December 21, 2022.