Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth 
#22, #23, #24, #25, #26, and #27. 
 
You asked the Plan to pre-approve the dental services. You say that the requested dental services are necessary 
because the enrollee has multiple previous fillings that continue to fail as loss of canine guidance. The Plan 
denied your request. The Plan says the denial of authorization for the dental services is correct, because the 
records show that the damage to the teeth is due to attrition, abrasion, erosion, abfraction. 
 
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 Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the dental services. Our reviewer says 
that the crowns and core buildup are not medically necessary. Our physician reviewer found that the x-rays 
show that there are fillings on teeth #23, #24, #25, and #26. The pulp space in the crown part of the tooth are 
not clear on the x-rays, and therefore I could not make the determination that the remaining tooth structure is 
close to the pulp. There were also photos included that are black and white. Some of the photos included were 
blurry. There is worn down tooth structure (attrition) noted on the teeth #22 and 27. There was also the 
following narrative included: These teeth have large restorations that show evidence of fracture, recurrent 
decay, and open margins. The buccal and lingual walls are undermined, and the enamel is tooth thin and will be 
unsupported. Full coverage protection is required.  
 
The photos do not show recurrent decay, or fracture lines, or open margins of the existing fillings. There is 
recession noted on some of the anterior teeth and this may contribute to the enrollees sensitivity, as the 
exposed areas are sensitive to hot and cold. Other treatment may help alleviate the enrollees chief concern 
regarding these teeth. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a crown (D2740) and core buildup (D2950) for tooth #22, #23, #24, #25, #26, and #27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 2 very heavy-duty power operated vehicle 
(POV) (K0808) and additional items and accessories (codes E2367, E2606, E2363 x2, and E2620). 
 
You asked the Plan to pre-approve a Group 2 very heavy-duty power operated vehicle and additional items and 
accessories. You say that in August of 2023, your motorized scooter of over five years stopped working, and 
you do not have the financial resources to have it repaired, as you are disabled and live on a fixed budget. The 
Plan denied your request. The Plan says group two motor scooters have extra features that are not needed at 
home. The Plan also says that this item is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that if a Group 2 POV (such as code K0808) is 
provided it will be denied as not reasonable and necessary. 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Group 2 very heavy-duty power operated vehicle and additional items and accessories have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 very heavy-duty power 
operated vehicle (POV) (K0808) and additional items and accessories (codes E2367, E2606, E2363 x2, and 
E2620).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve laminectomy, facetectomy, and foraminotomy at L4-5 
(63047). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of 
the requested services.  
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case.  
 
  
 
 
 
Our physician reviewer found that the enrollee was being treated for spinal stenosis of the lumbar region with 
neurogenic claudication. She presented noting her back feels the same, if not worse. The pain with walking is at 
10/10. She has improved symptoms at rest. The exam reveals no focal neurological deficits. However, detailed 
documentation regarding a trial and failure of recent, reasonable, comprehensive, less invasive conservative 
care measures is not evident. Moreover, there are no objective neurological deficits to corroborate the 
pathology noted on the recent imaging study. There are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this clinical setting. No compelling rationale is presented, or 
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
Therefore, the requested laminectomy, facetectomy, and foraminotomy at L4-5 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve laminectomy, facetectomy, and foraminotomy at L4-5 (63047).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a sacroiliac joint procedure provided on 
May 24, 2023. 
 
You asked the Plan to waive the copayment for a sacroiliac joint procedure. You say that you disagree with the 
copayment. 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 $275 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. 
 
You have been asked to pay a $275 copayment for a sacroiliac joint procedure. This item/service falls within 
the outpatient surgery, including services provided at hospital outpatient facilities 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 copayment for a sacroiliac joint procedure provided on May 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a medical eye examination (92004), computerized 
corneal topography (92025), and an ophthalmic biometry (92136). 
 
You asked the Plan to pre-approve a medical eye examination (92004), computerized corneal topography 
(92025), and an ophthalmic biometry (92136). You say that you do not want to continue with the surgery if this 
provider is not the referred provider. The Plan denied your request. The Plan says the provider is out-of-
network. The Plan also says that there are in-network facilities that have several locations and providers to 
choose from. 
 
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 medical eye examination (92004), computerized corneal topography (92025), and an ophthalmic biometry 
(92136).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on June 
8, 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 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 8, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on June 8, 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 the requested CGM is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the Medicare criteria was not met. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the CGM. Our reviewer says that the 
CGM coverage criteria was not met. Our physician reviewer found that the coverage criteria for a CGM 
requires insulin use or low blood sugars. This enrollee is taking Januvia alone. If the enrollee is indeed taking 
insulin, this information should be documented and clearly stated and supported by office notes and 
resubmitted for re-review. 
 
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 CGM have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a continuous glucose monitor (CGM).
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 you cannot be safely discharged home and require 
IRF services to regain your strength. The Plan denied your request. The Plan says the request is not medically 
necessary.  
 
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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy (45378), propofol injection (J2704), and 
ringers lactate infusion (J7120) provided on April 17, 2023, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the colonoscopy, propofol injection, and ringers lactate infusion. You say that an 
authorization was not obtained because colonoscopies did not require an authorization for in-network facilities. 
You also say that it was not known until the claim denied that the facility is no longer an in-network provider 
and would need authorization. The Plan denied your request. The Plan says the services were rendered by a 
non-network provider who does not work with the enrollee's plan, and the enrollee was referred by another 
non-network provider. The Plan also says that no medical necessity for an OON provider, such as an urgent or 
emergency situation, has been documented. 
 
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 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 the colonoscopy (45378), propofol injection 
(J2704), and ringers lactate infusion (J7120) provided on April 17, 2023, by an out-of-network (OON) 
provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for remote monitoring of physiologic parameters provided on 
May 01, 2023. 
 
You asked the Plan to pay for remote monitoring of physiologic parameters. You say that you are requesting 
reconsideration for the services provided. 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 remote monitoring of 
physiologic parameters provided on May 01, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for Part B  Injectable services provided on February 27, 2023. 
 
You asked the Plan to pay for Part B  Injectable services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that charges for or in connection with services or supplies that are, 
as determined by us, considered to be experimental or investigational are excluded from coverage under the 
member's Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for Part B  Injectable services 
provided on February 27, 2023.  
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medication assisted treatment (G2067) and take-home 
supply of methadone (G2078) provided on May 8, 2023, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the medication assisted treatment and take-home supply of methadone. You say 
that the clinic the enrollee was treated at is a walk-in clinic, not contracted with the Plan. You also say that a 
referral, authorization, precertification, or notification is not required. The Plan denied your request. The Plan 
says the treating provider is not a network provider with the Plan. The Plan also says that these services are not 
urgent or emergent, nor were they approved in advance. 
 
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 the medication assisted treatment (G2067) and 
take-home supply of methadone (G2078) provided on May 8, 2023, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy provided on May 16, 2022. 
 
You asked the Plan to pay for the physical therapy. You say that the enrollee's updated information was not 
received in time to submit the claim. The Plan denied your request. The Plan says the claim was filed on July 5, 
2023, without good cause. 
 
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 physical therapy was not filed until July 5, 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 the physical therapy provided on May 16, 2022.
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 the portable oxygen concentrator. You say that you need oxygen to get out 
of the home for your medical appointments and to do everything as you cannot walk without oxygen. You also 
say that you need oxygen at all times. The Plan denied your request. The Plan says you have been provided 
with a stationary oxygen concentrator and portable oxygen tanks to meet your needs for supplemental oxygen. 
 
The Plan must follow Medicare rules. The rules say that patients who are mobile in the home and would benefit 
from the use of portable oxygen in the home, may qualify for coverage of a portable oxygen system either by 
itself, or to use in addition to a stationary oxygen system. Oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication.  
 
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 portable oxygen concentrator Our 
reviewer says that the item is not medically necessary. Our physician reviewer found you met criteria for a 
home and portable O2 therapy, as shown by the six minute walk test. However, there is no evidence to show 
that you require a portable oxygen concentrator and cannot tolerate a O2 delivery system. Hence, there is no 
documentation to suggest a portable oxygen concentrator is required. 
 
 
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 portable oxygen concentrator have not been met.  Therefore, we decided 
that the Plan does not have to pre-approve a portable oxygen concentrator.