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

 
We decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, flexible 
protective outer surface covering system (L5962). 
 
You asked the Plan to pre-approve the additional outer surface covering system. You say that the enrollee 
needs the flexible protective skin to protect the prosthetic components from the environment. His prosthesis is exposed to excessive moisture and dust. The Plan denied your request. The Plan says the request for a second 
cover (L5962) exceeds the enrolle's need and does not meet Medicare criteria as reasonable and 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 additional outer surface covering 
system. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found in this case, there is no documentation of unusually harsh 
environmental situations for which a specialized lower limb prosthetic cover (L5962) is required and for which 
the approved prosthetic cover (L5704) would be insufficient. The review has determined that the medical 
records provided did not meet the requirements listed in the LCD for Medicare coverage. 
 
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 additional outer surface covering system have not been met. Therefore, we 
decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, flexible 
protective outer surface covering system (L5962).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 9, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from May 9, 2022, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary. 
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 inpatient psychiatric care from May 9, 
2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment 
beyond the date in question of May 9, 2022, forward. Our physician reviewer found you did not require 
inpatient mental health treatment beyond May 9, 2022, as you were not a danger to yourself or others and did 
not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking 
place beyond the date in question. It did not appear that the services for the dates in question were reasonably 
expected or medically necessary to improve your condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from May 9, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from May 9, 2022, 
forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and abutment 
supported porcelain fused to metal crown (D6059). 
 
You asked the Plan to pre-approve the custom fabricated abutment and abutment supported porcelain fused to 
metal crown. 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 a 
custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement crown (D2740) for teeth #8, #9, and #18 
to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve a replacement crown. You say that D2740 is medically necessary. The Plan 
denied your request. The Plan says there is not cavity under the old cap; therefore, D2740 (all white glass 
crown) is not medically necessary. 
 
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 a replacement 
crown 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 a replacement crown. Our reviewer 
says that the medical criteria for D2740 have not been met. Our physician reviewer found although the mesial 
margin appears to be poorly fitting there is no noted decay and the crown is still serviceable. 
 
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 a replacement crown have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a replacement crown (D2740) for teeth #8, #9, and #18 to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0366) and endodontic therapy (D3330) provided on December 15, 2021. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation and endodontic therapy. You say 
that the treating provider was in-network and accepted your insurance. You also say that you do not understand 
why these services are not covered. The Plan denied your request. The Plan says these services are not covered 
benefits under your dental plan. The Plan also says that you did not contact the customer service department 
prior to receiving the services to verify dental coverage. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam computed tomography (CT) capture and interpretation (D0366) and endodontic therapy (D3330) 
provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic-porcelain/ceramic (CPT code D2950), core build 
up (CPT code D6245), and retrainer crown (CPT code D6740 x3). 
 
You asked the Plan to pre-approve the dental services. You say that you have a broken front tooth, and it needs 
to be relaced. You state you have an infection in your gums for which you are taking medication. The Plan 
denied your request. The Plan says the services are not a covered benefit under the 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. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve pontic-
porcelain/ceramic (CPT code D2950), core build up (CPT code D6245), and retrainer crown (CPT code D6740 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown (D2750), 
full cast high noble metal crown (D2790), endodontic therapy on a bicuspid tooth (D3320), and endodontic 
therapy on a molar tooth (D3330). 
 
You asked the Plan to pre-approve the crowns and endodontic therapies. You say that you would like to appeal 
these services. 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 a 
porcelain fused to high noble metal crown (D2750), full cast high noble metal crown (D2790), endodontic 
therapy on a bicuspid tooth (D3320), and endodontic therapy on a molar tooth (D3330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve porcelain fused to high noble metal crowns (D2750) for 
seven (7) teeth. 
 
You asked the Plan to pre-approve crowns. You say that these services are medically necessary. The Plan 
denied your request. The Plan says crowns are not covered by your dental benefit. 
 
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 
porcelain fused to high noble metal crowns (D2750) for seven (7) teeth.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmologist services to be provided by the 
requested out-of-network provider. 
 
You asked the Plan to pre-approve the ophthalmologist services. The Plan denied your request. The Plan says 
no medical need is shown as to why you cannot get an ophthalmologist visit from a provider in your health 
Plan network. There is no network gap as there are available in-network providers. 
 
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 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 
ophthalmologist services to be provided by the requested out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair with accessories to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve power wheelchair. You say that you need this device to get around when 
you are out of bed. The Plan denied your request. The Plan says the denial of authorization for this device is 
correct, because this provider is out-of-network with the Plan and this device can be obtained from an in-
network equipment supplier. 
 
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 power wheelchair with accessories 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 acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee is medically stable and does not need PM&R physician close supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. At the current functional level, the enrollee does not need 3 hours a day five days a week of 
IRF therapies with interdisciplinary management and the enrollee's rehab needs can be met in an alternate and 
lower setting such as in a skilled nursing facility. 
 
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.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 the enrollee is medically stable and does not need PM&R physician close supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. The enrollee does not need 3 hours a day five days a week of IRF therapies with 
interdisciplinary management and the enrollee's rehab needs can be met in an alternate and lower setting such 
as in a skilled nursing facility. 
 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diagnostic medial branch block injections. 
 
You asked the Plan to pre-approve diagnostic medial branch block injections. The Plan denied your request. 
The Plan says Medicare coverage criteria for diagnostic medical branch block injections has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain. 
 
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 diagnostic medial branch block 
injections. Our reviewer says that diagnostic medial branch block injections are not medically necessary. Our 
physician reviewer found the first diagnostic medial branch block injection performed November 8, 2021 did 
not provide a minimum of 80% pain relief. The enrollee has radicular pain symptoms, that have not been 
treated. The review has determined that the requested facet joint injections are not medically reasonable or 
necessary according to the coverage criteria established in the above Medicare LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of diagnostic medial branch block injections have not been met. Therefore, we 
decided that the Plan does not have to pre-approve diagnostic medial branch block injections.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy requirements. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary in this case. Our physician reviewer found that based on 
the medical records ,the enrollee has not tried and failed the required drug(s). There is no indication that the 
plan's required drug(s) 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty wheelchair. You asked the Plan to pre-approve the requested wheelchair. You say that you have nerve damage and 
osteoarthritis. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that manual wheelchairs are only covered under 
certain medical indications.   
 
We looked at the file and Medicare rules. In this case, the records do not show that your mobility limitation 
cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. Based on this information, 
we decided that Medicare rules for coverage of the requested wheelchair have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a heavy-duty wheelchair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home dialysis services provided on June 16, 2021, 
through September 18, 2021. 
 
You asked the Plan to pay for the home dialysis services. You say that you would like reconsideration because 
these services were approved by the Plan. The Plan denied your request. The Plan says this provider is not 
eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the home dialysis services provided on 
June 16, 2021, through September 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-one (J7326). 
 
You asked the Plan to pre-approve Gel-one. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for the requested viscosupplements device. 
 
  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 Gel-one. Our reviewer says that Gel-
one is not medically reasonable and necessary for the enrollee. Our physician reviewer found the patient has 
not tried and failed the required drugs, Durolane, Monovisc or Synvisc-One. Our reviewer also found that there 
is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects 
for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-one have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-one (J7326).