Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mvasi and temsirolimus. 
 
You asked the Plan to pre-approve Mvasi and temsirolimus. 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 anti-cancer 
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 Mvasi and temsirolimus. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found the review has determined that 
the requested use of Mvasi and temsirolimus is not FDA-approved for the enrollees diagnosis. Their 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 Mvasi and temsirolimus have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Mvasi and temsirolimus.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation with field of 
view of one full dental arch  maxilla, with or without cranium (D0366) provided on May 22, 2023. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation. You say that you presented to the 
dentist for an emergency treatment and the cone beam CT was necessary for a diagnosis. The Plan denied your 
request. The Plan says this service is not a covered expense under your dental 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 pay for the cone 
beam CT capture and interpretation with field of view of one full dental arch  maxilla, with or without 
cranium (D0366) provided on May 22, 2023.
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 service is medically necessary. The Plan denied 
your request. The Plan says criteria for admission to the acute IRF setting have not been met.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery (22558, 22612, 22614, 22842, 
22845, 22853). 
 
You asked the Plan to pre-approve spinal fusion surgery. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 spinal fusion surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no spinal instability fracture or lesion. Multilevel spinal fusion for 
degenerative back pain is not medically 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 spinal fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal fusion surgery (22558, 22612, 22614, 22842, 22845, 22853).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete mandibular/maxillary dentures and maxillary 
denture repair services (D5512, D5110, D5120) provided on February 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for complete mandibular/maxillary dentures and maxillary denture repair services (D5512, D5110, 
D5120) provided on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a custom fabricated abutment  includes placement (D6057), 
and abutment supported porcelain/ceramic crown (D6058) provided on May 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were informed by your dentist that you had 
a porcelain crown with Zirconia instead of porcelain over metal based. You also say that you have $500.00 
coverage for crowns. The Plan denied your request. The Plan says these services are not benefits of the dental 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a custom 
fabricated abutment  includes placement (D6057), and abutment supported porcelain/ceramic crown (D6058) 
provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310), extraction, erupted tooth requiring removal of 
bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210), bone 
replacement graft for ridge preservation - per site (D7953), and guided tissue regeneration, natural teeth  
resorbable barrier, per site (D4266) provided on April 17, 2023. 
 
You asked the Plan to pay for a the dental services. You say that you were in desperate need for an emergency 
extraction of your tooth. You also say that you feel these services should be covered under your insurance.  The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a consultation - diagnostic service provided by dentist or physician other than requesting dentist or 
physician (D9310), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and 
including elevation of mucoperiosteal flap if indicated (D7210), bone replacement graft for ridge preservation - 
per site (D7953), and guided tissue regeneration, natural teeth  resorbable barrier, per site (D4266) provided 
on April 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower extremity revascularization procedure (37226). 
 
You asked the Plan to pre-approve a lower extremity revascularization procedure. 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 follows Medicare rules. Medicare rules say that PTA is covered when used under certain conditions. 
 
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 lower extremity revascularization 
procedure. Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not meet coverage criteria and does not support the medical necessity of the treatments in 
question. The narrative of symptoms appears to be copied and pasted from evaluation to evaluation. It is noted 
you were seen by vascular surgery but is not documented that the vascular team recommended intervention. 
The current evaluation is absent a pulse examination. Additionally, the documentation does not include an 
assessment in which there is a recommendation or plan to perform the procedures in question. Due to this lack 
of clarity, coverage criteria have not been met. 
 
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 lower extremity revascularization procedure have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lower extremity revascularization procedure (37226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
June 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were never told that this dentist was out-of-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental 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. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network provider on June 12, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided on May 22, 2023. 
 You asked the Plan to pay for the genetic testing. You say that records have been submitted to show medical 
necessity. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for genetic testing provided on May 22, 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 a CGM. You say that you would like the Plan to reconsider their denial. The 
Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary 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. The documentation 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 a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on December 
21, 2022. 
 
You asked the Plan to pay for the extraction. You say that you required a tooth to be extracted and you are a 
cardiac patient who was on special antibiotics for the tooth. You also say that you could not wait ten days until 
your new dental coverage to begin on January 1, 2023. The Plan denied your request. The Plan says service 
D7210 is not listed as 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 pay for an 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210) provided on December 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown for teeth #22, #23, #24, #25, #26, and #27 provided 
on February 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe the plan should pay for more. The 
Plan denied your request. The Plan says your annual dental allowance amount has 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 annual dental allowance amount was exhausted on date of service February 14, 2023.A crown and 
core build-up for tooth #21 was approved and paid. Therefore, we decided that the Plan does not have to pay 
for a crown for teeth #22, #23, #24, #25, #26, and #27 provided on February 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance treatment without transport provided on May 16, 
2023. 
 
You asked the Plan to pay for the ambulance treatment without transport. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the Medicare ambulance benefit is a 
transportation benefit and without a transport there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  The ambulance company did not provide transport services on May 16, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance treatment without transport provided 
on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110), and bitewings - four 
radiographic images (D0274) provided on June 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that since this was your first cleaning of the year you 
feel it should be covered, even if you have met your maximum for the year. The Plan denied your request. The 
Plan says your benefit for the requested services $2,000 dollar limit was met. 
 
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 January 16, 2023. 
Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110), and bitewings - 
four radiographic images (D0274) provided on June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy (97140) provided on April 6, 2023 and 
April 11, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the manual therapy (97140) provided on April 6, 2023 and April 11, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2751) for tooth #4 and #5 provided on May 
8, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the dental services should be covered 
since you pay monthly premium and you do not have the accurate information why the Plan denied the 
services. The Plan denied your request. The Plan says your annual maximum dental benefit for the year 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 $184.20 for dental services on February 7, 2023. On May 8, 2023, the Plan paid $815.80 
for the dental services. For the year of 2023 the Plan paid $1,000 ($184.20 paid + $815.80 paid) for dental 
services; therefore, your annual maximum dental benefit for the year of 2023 was exhausted on the date of 
service of May 8, 2023. Therefore, we decided that the Plan does not have to pay more for a crown (D2751) for 
tooth #4 and #5 provided on May 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810) and the chiropractic 
manipulative treatment (98940) rendered by the out-of-network (OON) provider on June 16, 2023.  
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not payable as they were 
rendered by an out-of-network provider, without prior authorization.  
  
 
 
 
 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the acupuncture treatment (97810) and the chiropractic manipulative treatment 
(98940) rendered by the out-of-network (OON) provider on June 16, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergency transport in a wheelchair van (A0130) 
provided on May 17, 2023. 
 
You asked the Plan to pay for non-emergency transport in a wheelchair van (A0130). You say that your dad 
could not stand after he had fallen. You also say you had to get him to general surgery, so you called a 
transportation service. The Plan denied your request. The Plan says transportation by gurney van is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport 
services.  
 
 
  The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided 
that the Plan does not have to pay for non-emergency transport in a wheelchair van (A0130) provided on May 
17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99203) provided on May 1, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99203) provided on May 1, 2023.