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

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you have chronic obstructive 
pulmonary disease (COPD) emphysema and cannot walk 15 minutes away from your apartment. You say that 
your lungs are so bad that you need oxygen and cannot stay in your hours 24 hours a day. The Plan denied your 
request. The Plan says a portable oxygen concentrator 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 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 portable oxygen concentrator 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 complete upper denture (D5110) and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. 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 February 1, 2023. 
Therefore, we decided that the Plan does not have to pre-approve complete upper denture (D5110) and partial 
lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitoring system 
(CGM). 
 
You asked the Plan to pre-approve the Dexcom G7 system. You say that your physician would like you to 
upgrade to the Dexcom G7 and you have access to this device. The Plan denied your request. The Plan says the 
documentation indicates that you already have an active authorization for a Dexcom G6 sensor. There is no 
record that it is missing or broken. 
 
The Plan must follow Medicare rules. Medicare rules say that equipment which the beneficiary owns or is a 
capped rental item may be replaced in cases of loss or irreparable damage. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Dexcom G7 system have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Dexcom G7 continuous glucose monitoring system (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation, of the nerves innervating the 
sacroiliac joint, with image guidance (64625).  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Sacroiliac Joint Injection (SIJ) Denervation  
also called Radiofrequency Ablation (RFA) is not considered reasonable and necessary. 
 
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of this service have not been met. Specifically, Medicare rules say that Sacroiliac Joint Injection (SIJ) 
Denervation also called Radiofrequency Ablation (RFA) is not considered reasonable and necessary. 
Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, of the nerves 
innervating the sacroiliac joint, with image guidance (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for needle localization by x-ray and an office 
visit on July 05, 2023. 
 
You asked the Plan to waive the copayments for needle localization by x-ray and an office visit. You say that 
you had these procedures for years and have not had to pay any extra because you haven't changed your plan. 
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 $95 
copayment for all other diagnostic procedures and tests. You must pay a $20 copayment for each Medicare-
covered specialist in-person or telehealth visit. For both services it's, $95 + $20 = $115. Therefore, results in 
the total cost sharing amount of $115. 
 
You have been asked to pay a $95 copayment for needle localization by x-ray and a $20 copayment for an 
office visit. This item/service falls within the outpatient diagnostic tests and therapeutic services and supplies 
and physician/practitioner services, including doctors office visits 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 copayments for needle localization by x-ray and an office visit on July 05, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cervical fusion surgery (22551, 22552, 22554, 22585, 
22845). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has degenerative discs and foraminal stenosis on imaging. However, there is no 
correlation between physical exam findings and imaging. There is no neurological deficit that corresponds to 
the imaging showing specific root compression. There is also no spinal instability or cord compression.   
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cervical fusion surgery (22551, 22552, 22554, 22585, 22845).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5225) and mandibular 
partial denture (D5226). 
 
You asked the Plan to pre-approve the dental services. You say that this 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 your benefit for the requested item or service was exhausted on date of service November 1, 2021. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture (D5225) and 
mandibular partial denture (D5226).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an in-network continuous positive airway 
pressure (CPAP) machine provided from March 18, 2022, to March 8, 2023. 
 
You asked the Plan to waive the coinsurance for a CPAP machine. You say that you switched between a 
BIPAP and CPAP and feel you are being double billed. 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 20% 
coinsurance for durable medical equipment (DME) and related supplies.  
 The allowed amount for both machines was $1,382.80. However, $1,075.80 was written off for the beneficiary. 
You are being asked to pay $307 for these dates of service ($1,382.80 - $1,075.80 = $307). 
 
You have been asked to pay $307 coinsurance for a CPAP machine. This item/service falls within the durable 
medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay 
the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for an in-network continuous positive airway pressure (CPAP) machine provided from March 18, 
2022, to March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve complete lower denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. 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 February 1, 2023. 
Therefore, we decided that the Plan does not have to pre-approve complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - porcelain/ceramic - tooth #3 (D2740). 
 
You asked the Plan to pre-approve a crown - porcelain/ceramic. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. 
 
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 
crown - porcelain/ceramic - tooth #3 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain or ceramic crown (D6740) for teeth numbers 
26 and 27. 
 
You asked the Plan to pre-approve the dental services. You say that you need this urgently. You also say you 
do not want to lose the $5,000 benefit due to the fact that the year is about to end. 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 with this preauthorization. The record 
shows you requested six procedure codes, and the Plan limit is four per year. Therefore, we decided that the 
Plan does not have to pre-approve a porcelain or ceramic crown (D6740) for teeth numbers 26 and 27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of reaction producing foreign bodies, 
musculoskeletal system (D7540). 
 
You asked the Plan to pre-approve the removal of reaction producing foreign bodies, musculoskeletal system 
(D7540). You say that you want to go to this provider as there is no in-network provider. You also say you trust 
him and know he can complete the treatment. The Plan denied your request. The Plan says this service is not 
covered under the members dental 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 the 
removal of reaction producing foreign bodies, musculoskeletal system (D7540).
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 a portable oxygen 
tank while traveling to your appointments. You say that the tank you currently have only last for two hours 
outside your home and your need at least 3-4 hours. The Plan denied your request. The Plan says that a portable 
oxygen system for use outside the home is not a covered benefit. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve platelet rich plasma injections. 
 
You asked the Plan to pre-approve platelet rich plasma injections. You say that you have a tear in your right hip 
and knee which causes pain while sitting and driving. You say that you were told surgery is out and you have 
exhausted all treatment options. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that there is insufficient high-quality evidence to 
justify the use of PRP for the treatment of any condition except for within the confines of a well-designed 
clinical trial. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of platelet rich plasma injections have not been met. Specifically, platelet rich plasma injections are 
not considered medically necessary. Therefore, we decided that the Plan does not have to pre-approve platelet 
rich plasma injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve semi precision attachment placement (D6192) 
 
You asked the Plan to pre-approve semi precision attachment placement . You say that this should be covered. 
The Plan denied your request. The Plan says this is not a covered service. 
 
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 semi 
precision attachment placement (D6192)
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer with decompression at 
lumbar spine level L3-4. 
 
You asked the Plan to pre-approve the Vertiflex interspinous spacer. You say that you strongly disagree with 
the denial for the surgery. The appellant says the surgery is medically necessary. The Plan denied your request. 
The Plan says the service is not medically necessary. The Plan says the spacer has not been shown to be more 
effective than standard spinal surgery or other standard treatments.  
 
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 interspinous spacer. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental, and more research is needed.  
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 interspinous spacer have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the Vertiflex interspinous spacer with decompression at lumbar spine 
level L3-4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve an office visit. You say that you say that you changed your PCP hoping it 
would be accepted where your oncologist is, and where you have been in care with the provider for 5 years. 
 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 of 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. 
 
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 
an office visit 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 waive the coinsurance for a walker on August 26, 2022, to May 26, 
2023. 
 
You asked the Plan to waive the coinsurance for a walker. You say that you were not told this was a rental and 
you returned the walker. 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 20% 
coinsurance for all other covered DME items. The following amounts were billed; 
 
The allowed amount of $5.84 x 20% = $1.17. 
The allowed amount of $5.84 x 20% = $1.17. 
The allowed amount of $5.84 x 20% = $1.17. 
The allowed amount of $11.68 x 20% = $2.34. 
The allowed amount of $11.68 x 20% = $2.34. 
The allowed amount of $11.68 x 20% = $2.34. 
The allowed amount of $11.68 x 20% = $2.34. 
The allowed amount of $11.68 x 20% = $2.34. 
The allowed amount of $11.68 x 20% = $2.34. 
The allowed amount of $11.68 x 20% = $2.34. 
 
For all services it's, $1.17 + $1.17 + $1.17 + $2.34 + $2.34 + $2.34 + $2.34 + $2.34 + $2.34 + $2.34 = $19.89. 
Therefore, results in the total cost sharing amount of $19.89. 
 
You have been asked to pay a 20% coinsurance for each walker service. This item/service falls within the 
durable medical equipment (DME) and related supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for a walker on August 26, 2022, to May 26, 2023.
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 the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria was not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. Specifically, the request for information from the enrollees 
physician indicates that the enrollee does not use insulin or have a history of problematic hypoglycemia. Based 
on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you had surgery and to recover from it the 
inserts are necessary to help you walk. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.