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

 
We decided that the Plan does not have to pre-approve a knee orthosis (L1833). 
 You asked the Plan to pre-approve an orthosis. You say that the enrollee's medical records do establish the need 
for a right knee brace. The Plan denied your request. The Plan says the records did not show that the enrollee 
has a medical necessity for the service.  
 
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 orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the clinical documentation provided does not support the need for a knee orthosis. The enrollee 
has a medical history of right knee osteoarthritis and is noted to have significant degeneration in the medial 
compartment and patellofemoral compartment and failed treatment with medications and knee injections. 
However, the physical examination does not demonstrate knee instability and there is no indication of recent 
trauma or surgery. The brace is being order to primarily offload the enrollee'ss knee joint, which is not 
indicated per the guideline policy. Therefore, the requested knee orthosis (L1833) is not 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 an orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (L1833).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6540. 
 
You asked the Plan to pre-approve the compression stockings. You say that the compression sleeve is 
medically necessary for the enrollee, and it will prevent unnecessary visits to the emergency room. The Plan 
denied your request. The Plan says the requested compression stockings are not covered by Medicare or the 
Plan. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6540 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6540.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from February 24, 2023, to March 
25, 2023. 
 
You asked the Plan to pay for home health care. You say that the Notice of Admission (NOA) was submitted 
electronically. The Plan denied your request. The Plan says the start of care date on the claim does not match 
the start of care date on the NOA. 
 
The Plan must follow Medicare rules. Medicare rules say that the home health agency must submit a start of 
care date matching the admission date reported on the first period of care.  
 
We looked at the file and Medicare rules. The Notice of Admission (NOA) for this home health period of care 
records an admission date of January 24, 2023. However, the final claim was billed with an admission date of 
January 25, 2023. Therefore, the admission date was not reported correctly. Based on this information, we 
decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the 
Plan does not have to pay for home health care provided from February 24, 2023, to March 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the biologic material to aid in osseous (D4265) for tooth 
#10, the implant supported to crown (D6065) for tooth #8, the placement of intra-socket biological dressing 
(D7922) for tooth #10, and the osseous (D7950). 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically 
necessary because the enrollee's crown fell out. The Plan denied your request. The Plan says the enrollee's 
benefit for the implant supported to crown has already been exhausted. Also, the biologic material to aid in 
osseous, the placement of intra-socket biological dressing, and the osseous are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for the implant supported to crown (D6065) for tooth #8 on September 20, 2022; therefore, 
the enrollees benefit for the the implant supported to crown (D6065) for tooth #8 was exhausted on the date of 
service of September 20, 2022. The biologic material to aid in osseous, the placement of intra-socket biological 
dressing, and the osseous are not covered under the Plans dental benefit. Therefore, we decided that the Plan 
does not have to pre-approve the biologic material to aid in osseous (D4265) for tooth #10, the implant 
supported to crown (D6065) for tooth #8, the placement of intra-socket biological dressing (D7922) for tooth 
#10, and the osseous (D7950).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on March 17, 2023. 
 
You asked the Plan to pay for ambulance services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on March 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is medically necessary. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for approval of the requested 
ventilator. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
 
 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 home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has severe COPD and 
was recently hospitalized with an exacerbation. An arterial blood gas when acutely ill on June 2, 2023, was 
consistent with acute on chronic hypercarbic respiratory failure. There is no diagnosis of thoracic restrictive 
disease or neuromuscular disease. The enrollee may benefit from bilevel positive airway pressure (BiPAP) with 
average volume-assured pressure support (AVAPS) during sleep. Medicare does not cover a home ventilator 
when used at settings that can be provided with BiPAP. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve epidural steroid injections (ESIs). 
 
You asked the Plan to pre-approve epidural steroid injections. You say that it is medically necessary. The Plan 
denied your request. The Plan says there has been no radiologic evidence submitted to support the diagnosis of 
lumbar spondylosis with radiculopathy. 
 
The Plan follows Medicare rules. Medicare rules say that the ESIs must be performed under computed 
tomography or fluoroscopy image guidance with contrast, unless the patient has a documented contrast allergy 
or pregnancy where ultrasound guidance without contrast may be considered. 
 
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 epidural steroid injections. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found there is no imaging 
presented here. Therefore, the request does not meet the LCD criteria.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the 
Plan does not have to pre-approve epidural steroid injections (ESIs).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 21, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a protective restoration (D2940). We also decided that the 
Plan does not have to pay more for a palliative (emergency) treatment of dental pain (D9110) provided on 
April 17, 2023.  
You asked the Plan to pay for a protective restoration (D2940) and to pay more for a palliative (emergency) 
treatment of dental pain (D9110). You say that this was not an emergency as your tooth was already broken for 
two weeks. You also say that the cost for the restoration is too much. The Plan denied your request. The Plan 
says a protective restoration (D2940) is not a covered benefit. The Plan also says that the cost sharing for a 
palliative (emergency) treatment of dental pain (D9110) was charged correctly. 
 
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 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 50% 
coinsurance for comprehensive dental services. This includes palliative (emergency) treatment of dental pain 
(D9110). 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, a protective restoration (D2940) is not 
among those covered under this benefit. 
 
You have been asked to pay $19 in coinsurance, which is 50% of the allows amount for a protective restoration 
(D2940). This item/service falls within the comprehensive dental services benefit category. The record shows 
that you received this service. 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 pay for a protective restoration (D2940). We also decided 
that the Plan does not have to pay more for a palliative (emergency) treatment of dental pain (D9110) provided 
on April 17, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services provided on March 16, 2023. 
 
You asked the Plan to pay for the psychotherapy services. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the psychotherapy 
services provided on March 16, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the drug, Orgovyx Tab 120mg 
 
You asked the Plan to pre-approve the medication. The Plan denied your request. The Plan says the medication 
is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the drug, Orgovyx Tab 
120mg
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of a dental implant (D6010), a 
custom abutment (D6057), and an abutment support to crown (D6058) for tooth #5. 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denied dental 
implant services. The Plan denied your request. The Plan says the denial of authorization for these services is 
correct, because dental implants and all associated services are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical placement of a dental implant (D6010), a custom abutment (D6057), and an abutment support to 
crown (D6058) for tooth #5.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
March 28, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service March 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 07, 2023. 
 
You asked the Plan to pay for a home visit. You say that the assisted living facility is responsible to obtain 
prior authorization for all of their patients. The Plan denied your request. The Plan says that unauthorized, out-
of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
February 07, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Prolia. 
 You asked the Plan to pre-approve Prolia. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of - or contraindication to - zoledronic acid before it 
will approve Prolia. 
 
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 Prolia. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Prolia. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drug of zoledronic acid. The record does not show that this 
drug would likely be less effective and/or 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for laboratory services provided on March 13, 
2023. 
 
You asked the Plan to waive the cost share for laboratory services. You say that you disagree with the cost 
share. 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. Your 
contract with the Plan says that there is a $525 deductible and a $10 copayment which applies to outpatient 
diagnostic tests/lab.  
 
The item or service you asked the Plan to waive the cost share for falls within the outpatient diagnostic tests/lab 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $525 
deductible and a $10 copayment which applies to outpatient diagnostic tests/lab. The total amount you are 
being asked to pay is $105.57 towards your $525 deductible. This cost sharing is a contractual obligation that 
had not been met at the time laboratory services was received on March 13, 2023. Therefore, we decided that 
the Plan does not have to waive the cost share for laboratory services provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a crown (D2740) and core buildup (D2950) for tooth #10. We 
decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth #5.  
 You asked the Plan to pre-approve crowns (D2740) and core buildup (D2950) for tooth #5 and #10. You say 
that you fell and cracked your tooth on pavers. You say you have called the Plan multiple times to no avail. The 
Plan says that the x-rays received do not display the correct tooth or are not of diagnostic quality. 
 
We decided that the Plan has to pre-approve a crown (D2740) and core buildup (D2950) for tooth #10. 
 
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 crown (D2740) and core buildup 
(D2950) for tooth #10. Our physician reviewer found that a crown (D2740) and core buildup (D2950) are 
medically reasonable and necessary for tooth #10. The x-rays and photo included in the clinical documentation 
show that the tooth has been fractured significantly and the procedures D2740 and D2950 are necessary to 
restore the tooth. Therefore, we decided that the Plan has to pre-approve D2740 and D2950 for tooth #10 .  
 
We also decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) 
for tooth #5. 
 
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 crown (D2740) and core buildup 
(D2950) for tooth #5. Our physician reviewer found that there is not enough information provided to determine 
whether or not a crown (D2740) and core buildup (D2950) are medically reasonable and necessary for tooth 
#5. The predetermination form states D2740 and D2950 have been recommended because the tooth has a large 
amalgam restoration with fracture; however, a fracture is not evident with the x-rays provided. Therefore, we 
decided that the Plan does not have to pre-approve D2740 and D2950 for tooth #5. 
 
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.