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

 
We decided that the Plan has to pre-approve pontic - porcelain/ceramic (D6245) Tooth #24 and retainer crown 
- porcelain/ceramic (D6740) Tooth #23 & 25. 
 
You asked the Plan to pre-approve dental services. You say that alternative treatments would cost more. The 
Plan denied your request. The Plan says that they denied the bridge and no information was provided 
explaining why a denture cannot be used. 
 
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 dental 
services 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 dental services. Our physician reviewer 
found a review of the documentation indicates that tooth #24 is to be extracted due to a root fracture. There are 
no other teeth missing in the lower arch. It is medically reasonable to replace a missing anterior tooth with a 
fixed bridge when there are no other teeth missing in the arch. 
 
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 dental services have been met. Therefore, we decided that the Plan has to pre-
approve pontic - porcelain/ceramic (D6245) Tooth #24 and retainer crown - porcelain/ceramic (D6740) Tooth 
#23 & 25.  
 
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 special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that your provider completed the attestation, and 
you have a heart disease. The Plan denied your request. The Plan says the criteria for eligibility have not been 
met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve core buildup, including any pins when required tooth # 29 
(D2950). We decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic tooth #'s 
18, 20, 29, and 31 (D6740), and pontic - porcelain/ceramic tooth #'s 19 and 30 (D6245).  
 
You asked the Plan to pre-approve a retainer crown - porcelain/ceramic tooth #'s 18, 20, 29, and 31 (D6740), 
pontic - porcelain/ceramic tooth #'s 19 and 30 (D6245), and core buildup, including any pins when required 
tooth # 29 (D2950). You say that this service will benefit the enrollee. The Plan says that the services are not 
medically necessary. 
 
We decided that the Plan has to pre-approve core buildup, including any pins when required tooth # 29 
(D2950).  
 
We also decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic tooth 
#'s 18, 20, 29, and 31 (D6740), and pontic - porcelain/ceramic tooth #'s 19 and 30 (D6245). 
 
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 retainer crown - porcelain/ceramic 
tooth #'s 18, 20, 29, and 31 (D6740), pontic - porcelain/ceramic tooth #'s 19 and 30 (D6245). Our reviewer says 
that the documentation does meet the criteria for coverage for a core buildup for tooth #29. Our physician 
reviewer found the appeal is being requested for the denial of coverage for fixed bridges replacing missing 
teeth #'s 19 and 30 with pontics (D6245) using teeth #'s 18, 20, 29 and 31 as abutment retainers (D6740) and a 
core buildup (D2950) for tooth #29. The reason for the denial was that the service does not meet the criteria for 
coverage. The documentation provided indicates that the patient is missing bilateral posterior teeth (#'s 19 and 
30). Coverage for fixed bridges is only considered to replace a single maxillary anterior tooth or two adjacent 
mandibular anterior teeth when there are no missing posterior teeth. 
 
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 retainer crown - porcelain/ceramic tooth #'s 18, 20, 29, and 31 (D6740), 
pontic - porcelain/ceramic tooth #'s 19 and 30 (D6245) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a retainer crown - porcelain/ceramic tooth #'s 18, 20, 29, and 31 (D6740), and 
pontic - porcelain/ceramic tooth #'s 19 and 30 (D6245). 
 
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 special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you believe that you meet the criteria and 
would like to appeal the denial. The Plan denied your request. The Plan says the criteria for eligibility have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns fused to base (D6751), pontics (D6252), and the 
operating room services (D9500) for tooth #21, #22, #23, #24, #25, #26 and #27. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
services because the dental bridge was not approved. The Plan denied your request. The Plan says the enrollee 
is missing multiple posterior teeth and a partial lower denture was approved to replace missing teeth. 
 
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 the dental 
services 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 the dental services. Our reviewer says 
that the documentation provided does not meet the criteria for coverage for a fixed bridge replacing teeth #24 
and #25 with pontics using #21, #22, #23, #26, and #27 as abutment retainers. Our physician reviewer found 
that the documentation indicates that the enrollee has multiple missing posterior teeth in the posterior mandible. 
A complete maxillary denture has been indicated. A mandibular partial denture would be the standard of care 
since coverage for a fixed bridge only covers a single mandibular anterior tooth when no posterior teeth are 
missing. 
 
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 the crowns fused to base and pontics have not been met. The operating room 
services is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to 
pre-approve crowns fused to base (D6751), pontics (D6252), and the operating room services (D9500) for tooth 
#21, #22, #23, #24, #25, #26 and #27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need this to use outside 
your home. The Plan denied your request. The Plan says duplicate equipment is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pre-approve a portable oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro orthotic device. 
 
You asked the Plan to pre-approve the MyoPro orthotic device. You say that the MyoPro device is medically 
necessary for the patient. The Plan denied your request. The Plan says there are only a few publications in the 
literature that examine the efficacy of the MyoPro in rehab for chronic stroke patients. The sample size of these 
studies is very small, and none of the studies showed that the use of MyoPro was superior to traditional rehab. 
As a result, this device is considered experimental/investigational for the patient's condition. 
 
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 the MyoPro orthotic device. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found current clinical guidelines for adult stroke rehabilitation and recovery designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb 
exercise therapies" with unproven benefit in the home environment. In addition, provided records report left 
upper extremity spasticity requiring Botox injections which may be a contraindication to use of the device.  
 
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 MyoPro orthotic device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the MyoPro orthotic device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 You asked the Plan to pre-approve OON physical therapy services. You say that you need care while you are in 
Florida. The Plan denied your request. The Plan says these circumstances are not unforeseen, and care is 
available in-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 Plan contract 
also says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal 
dialysis and pre-approved care.   
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical 
therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an inpatient level of care for treatment. 
 
You asked the Plan to pre-approve an inpatient level of care for treatment. You say that the requested inpatient 
level of care for treatment is medically necessary. The Plan denied your request. The Plan says the requested 
inpatient level of care for treatment is 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 an inpatient level of care for treatment. 
Our reviewer says that the requested inpatient level of care for treatment is not medically necessary at this time. 
Our physician reviewer found in this case based on the records provided, it cannot be determined if the services 
to be provided necessitate the inpatient level of care as defined by guidelines. More specifically, the guidelines 
indicated "Inpatient care rather than outpatient care is required only if the beneficiary's medical condition, 
safety, or health would be significantly and directly threatened if care was provided in a less intensive setting." 
 
It was not clear that the notes provided that the member's treatment could not at least be started in the 
observation setting. If the admission spreads after 2 midnights, it could then be upgraded to the inpatient level 
of care. A tiered approach would therefore meet but not exceed the member's overall clinical needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an inpatient level of care for treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an inpatient level of care for treatment.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device. 
 
You asked the Plan to pre-approve the Vertiflex Superion interspinous spacer device. The Plan denied your 
request. The Plan says this is 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 the Vertiflex Superion interspinous 
spacer device. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is 
needed for this device. 
 
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 Vertiflex Superion interspinous spacer device have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and related 
supplies (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and related supplies. You say that the 
requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says the request 
is not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
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 pneumatic compression device and 
related supplies. Our reviewer says that the requested items are not medically reasonably and necessary in this 
case. Our physician reviewer found that the provided records in this case do not document at least four weeks 
of regular, daily, multiple-hour home usage of a basic pump (E0650 or E0651) after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. 
 
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 pneumatic compression device and related supplies have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and 
related supplies (E0656, E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2. 
 
You asked the Plan to pre-approve a Freestyle Libre 2.. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the member does not use insulin with at least three daily injections. 
 
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 
Freestyle Libre 2. have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Freestyle Libre 2.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311), harness for upgrade 
to expandable controller (E2313), and expandable controller (E2377). 
 
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested features 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 the accessories. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the patient does not require non-proportional input devices (e.g., sip and puff, head array, 
etc.).The patient does not require a separate display (i.e., for alternate control devices), other electronic devices 
(e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant 
control. The documentation does not support that it is medically necessary to control the requested power 
options through the joystick (drive interface). The patient's  upper extremity strength and functional ability as 
evidenced by being able to perform activities of daily living independently should be sufficient to control any 
power options through their own switches. The documentation does not reveal that the E2377 Expandable 
Controller, E2313 Expandable Controller Harness and E2311 Electro Connect Btw 2 Sys Electro Connect Btw 
2 Sys are 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 accessories have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an electronic connection (E2311), harness for upgrade to expandable controller (E2313), 
and expandable controller (E2377).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eylea. 
 You asked the Plan to pre-approve Eylea. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Eylea. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of Puckering of macula, bilateral. On March 24, 2023, it is documented that 
the enrollee has new neovascular AMD with active CNV OD. The documentation does not support that the 
enrollee has tried and failed Bevacizumab. 
The documentation does not support that bevacizumab would likely be less effective and/or likely have adverse 
effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies, disposable underpads, and body 
wipes. 
 
You asked the Plan to pre-approve incontinence supplies, disposable underpads, and body wipes. You say that 
you cannot get up and go to the bathroom. The Plan denied your request. The Plan says the requested supplies 
are not covered. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies, disposable 
underpads, and body wipes are not covered because they are hygienic items that are non-reusable.  
 
While incontinence supplies, disposable underpads, and body wipes 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 incontinence supplies, disposable underpads, and body wipes.