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

 
We decided that the Plan does not have to pre-approve the OneTouch Ultra test strips. 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that the enrollee has been using the 
requested test strips on and off and it is working for them. The Plan denied your request. The Plan says only the 
preferred brand products listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve the 
OneTouch Ultra test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia for the first 15 minutes 
(D9222), deep sedation/general anesthesia for each subsequent 15 minute increments (D9223) and a 
therapeutic parenteral drug (D9610).  
 
You asked the Plan to pre-approve deep sedation/general anesthesia for the first 15 minutes (D9222), deep 
sedation/general anesthesia for each subsequent 15 minute increments (D9223) and a therapeutic parenteral 
drug (D9610). You say that you are appealing with supporting records. The Plan denied your request. The Plan 
says these services are not covered on your 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 deep 
sedation/general anesthesia for the first 15 minutes (D9222), deep sedation/general anesthesia for each 
subsequent 15 minute increments (D9223) and a therapeutic parenteral drug (D9610).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart. 
 
You asked the Plan to pre-approve the CT scan. You say that the test is needed for diagnostic purposes. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 CT scan. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found coronary calcium scoring is recommended 
only in individuals with moderate cardiovascular events risk to adopt or accept starting on statins, if the patient 
is hesitant. The records do not show that the enrollee meets this 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 the CT scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the heart.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010), abutment 
supported crown (D6058), radiographic/ surgical implant (D6190), osseous surgery (D4260, D4261), custom 
fabricated abutment (D6057). 
 
You asked the Plan to pre-approve these dental services. 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 
surgical placement of implant body (D6010), abutment supported crown (D6058), radiographic/ surgical 
implant (D6190), osseous surgery (D4260, D4261), custom fabricated abutment (D6057).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT capture and interpretation with field of view 
of both jaws, with or without cranium (D0367) provided on April 17, 2023. 
 
You asked the Plan to pay for cone beam CT capture and interpretation. 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 pay for cone 
beam CT capture and interpretation with field of view of both jaws, with or without cranium (D0367) provided 
on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation services. 
 
You asked the Plan to pre-approve additional non-emergency transportation services. You say that you are 
legally blind and require this service for her medical appointments. The Plan denied your request. The Plan 
says additional trips in excess of thirty one-way trips are non-covered by the health plan. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 30 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on December 13, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for an office visit. You say that you disagree with the denial. The Plan denied your 
request. The Plan says you receive care from an out-of-network provider, and it 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on December 13, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the outpatient T11 kyphoplasty (22513).  
 
You asked the Plan to pre-approve the outpatient T11 kyphoplasty. You say that the kyphoplasty is medically 
necessary.  The Plan denied your request. The Plan says the T11 kyphoplasty 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 reviewed the Local Coverage Determination cited by the Plan and found that it 
is not applicable to the state where the requested service will be performed. 
 
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 outpatient T11 kyphoplasty. Our 
reviewer says that the requested surgery is not considered medically reasonable and necessary in this case.  Our 
physician reviewer found the enrollee was being treated for age-related osteoporosis with current pathological 
fracture. The documentation is not evident regarding the current vertebral fracture being greater than 25% or 
the progression of the body height loss. Additionally, the provided thoracic magnetic resonance imaging (MRI) showed other plausible causes of the pain. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this clinical setting. There is no compelling rationale or 
extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the 
requested kyphoplasty at T11 is not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the outpatient T11 kyphoplasty have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the outpatient T11 kyphoplasty (22513).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network nephrologist. 
 
You asked the Plan to pre-approve these services. You say that you would like to see this provider for the best 
possible care. The Plan denied your request. The Plan says the services are available from 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 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 referral to an out-of-network nephrologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 24 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you are requesting additional routine 
transportation trips because you have surgeries and important medical procedures that need to be scheduled as 
soon as possible. The Plan denied your request. The Plan says the trip report confirms that you have used all 48 
one-way trips.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve the 
additional transportation for your medical procedures. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve 24 additional routine transportation trips (A0120).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support and ground 
mileage provided on October 28, 2021. 
 
You asked the Plan to pay for the ambulance service and ground mileage. You say that you have submitted 
proof of the timely filing and request to reprocess the claim. The Plan denied your request. The Plan says the 
claim was untimely, and the submission did not meet the exception criteria guidelines outlined in 42 CFR 
Section 424.44. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
 
 The record shows that a claim for the ambulance service and ground mileage was not filed until February 25, 
2023. This means that more than one calendar year from the date of service had passed before a claim was 
filed. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life support 
and ground mileage provided on October 28, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits (97110, 97163) to be provided by 
an OON provider.  
 
You asked the Plan to pre-approve physical therapy visits (97110, 97163). You say that you would like to use 
the out-of-network provider because you went to them in 2019. The Plan denied your request. The Plan says 
the service can be provided by an in-network provider. 
 
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 
physical therapy (97110, 97163) to be provided by an 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 enrollee requires the level of care provided at an 
IRF. The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare 
requirements for an IRF admission.  
 
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 does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve Prolia. You say that the enrollee has chronic kidney disease, and the 
requested drug should have been approved.  The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
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 Prolia is 
not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drug bisphosphonate. Also, there is no indication that the Plan's required drug would likely be less 
effective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lucentis. 
 You asked the Plan to pre-approve Lucentis. The Plan denied your request. The Plan says that the step therapy 
requirements have not been met. 
 
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 Lucentis. Our reviewer says that 
Lucentis is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the 
Plan's required drug Byooviz. Also, there is no indication that the Plan's required drug would likely be less 
effective or likely have adverse effects for you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Lucentis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on May 3, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that the compression stockings were 
medically necessary for your medical condition, and you were never advised that you would be responsible for 
them. The Plan denied your request. The Plan says the compression stocking is not covered by Medicare or the 
Plan. The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 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 pay for the compression 
stockings identified with code A6530 that were issued on May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergent transportation benefits 
(A0100). 
 
You asked the Plan to pre-approve additional non-emergent transportation benefits (A0100). You say that you 
have multiple doctors' appointments and needs transportation. The Plan denied your request. The Plan says 
your request exceeds the benefit limit for the transportation program. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 100 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergent transportation benefits (A0100).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5212) and a maxillary 
partial denture (D5211). 
 
You asked the Plan to pre-approve a mandibular partial denture (D5212) and a maxillary partial denture 
(D5211). You say that you are appealing with supporting records. The Plan denied your request. The Plan says 
this service is not covered in 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 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 
mandibular partial denture (D5212) and a maxillary partial denture (D5211).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a visual field examinations (92081) and vision supplies or 
accessories (V2797) provided on May 4, 2023. 
 
You asked the Plan to pay for a visual field examinations (92081) and vision supplies or accessories (V2797). 
You say that there was a denied payment for these services. The Plan denied your request. The Plan says these 
services are not covered by the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when . 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover routine eye examinations (includes 
refraction) (1 per calendar year) by a Plan network optical provider. Visual field examinations (92081) and 
vision supplies or accessories (V2797) are excluded from this benefit. Based on this information, we decided 
that the Plan's rules for coverage of a visual field examinations (92081) and vision supplies or accessories 
(V2797) have not been met. Therefore, we decided that the Plan does not have to pay for a visual field 
examinations (92081) and vision supplies or accessories (V2797) provided on May 4, 2023.