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

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the enrollee's condition requires a SNF admission. 
The Plan denied your request. The Plan says the requested services can be provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee recently returned home in November 2022, following a SNF stay for a 
hip fracture repair. The enrollee has chronic functional loss refractory to skilled therapy, and she has no daily 
skilled nursing needs.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve knee orthosis (L1833 x2). 
 
You asked the Plan to pre-approve knee orthosis. 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 a knee orthosis is covered when specific criteria are 
met. 
 
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 knee orthosis. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation does not reveal 
evidence of objective joint laxity or instability on a physical examination. There is no evidence of a recent 
injury or surgery to the knees. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve knee orthosis (L1833 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3225).  
 
You asked the Plan to pre-approve foot orthotics. You say that the items should be covered as the enrollee 
disagrees with the denial. 
 The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
  Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. 
Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of 
orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot 
orthotics (L3225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interim partial denture (D5821). 
 
You asked the Plan to pre-approve 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 services denied correctly as they do 
not fall within your dental 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. 
 
 
  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 an 
interim partial denture (D5821).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of an interspinous stabilization device 
(22869). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee was being treated for spinal stenosis of the lumbar region with neurogenic claudication. 
She presented with lower back and right lower extremity pain. The pain is rated at 7/10 on average and 10/10 at 
its worst.   
 
 
However, current evidence based medical guidelines and peer reviewed literature do not fully support the 
spinal decompression device procedure over the gold standard of a lumbar laminectomy. There is a lack of 
large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollees 
medical condition. The Food and Drug Administration (FDA) indications include implantation of the 
stabilization device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom 
operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees 
of spinal stenosis, many not at FDA indicated levels of moderate spinal stenosis (including the planned level 
of implantation of L3-4.) FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, 
and have not been adequately addressed in the medical records. There is imaging evidence of moderate L3-4 
and mild L4-5 rightward lateral listhesis, grade 1 anterolisthesis of L3 on L4 with no discussion of spinal 
instability on flexion/extension films. There is imaging evidence of a dextrocurvature of the lumbar spine with 
no documentation of the Cobb angle. There is no discussion indicating that a dual-energy x-ray absorptiometry 
(DEXA) scan has demonstrated the lack of significant osteoporosis in this patient. There is no compelling 
rationale presented or extenuating circumstances noted to support the medical necessity of this request as an 
exception. Therefore, the requested interspinous spacer at L3-4, in this case, 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the insertion of an interspinous stabilization device (22869).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the enrollee meets criteria for a ventilator 
approval as he has now tried and failed BIPAP. The Plan denied your request. The Plan says that the records 
show that the ventilator is going to be used only in a bi-level pressure mode. 
 
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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not reasonable and 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 a home ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the enrollee has COPD and chronic 
respiratory failure. The enrollee has documented failure of BIPAP and already has begun home ventilator with 
good compliance and improvement in symptoms and disease control. Hence, the enrollee should be continued 
on a home ventilator per data and documentation provided.  This would be best practice, to continue the home 
ventilator prescribed and in use. 
 
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 been met. Therefore, we decided that the Plan has to 
pre-approve a home ventilator (E0466).  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment services without transport 
services received on July 5, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment services without transport. You say that 
the enrollee does not recall these services. The Plan denied your request. The Plan says without transport there 
are no payable services. 
 
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 July 5, 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 response and treatment services 
without transport services received on July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5298) provided on June 21, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5298). You say that the hearing aids you purchased in 2020 
are no longer effective. You also say that you are on a fixed budget, so you purchased new ones from this 
provider. You also say that the time period between the purchases of hearing aids is three years and five 
months. The Plan denied your request. The Plan says their records indicate the maximum benefit has been 
exhausted. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan can 
reimburse you $1,000 every 4 years.  
 
 
  We looked at the file, and the Plan's rules. The Plan rules say that they will reimburse you $1,000 for hearing 
aids every four years. The record shows that this benefit was exhausted on February 19, 2020. Based on this 
information, we decided that the Plan's rules for coverage of hearing aids (V5298) have not been met. 
Therefore, we decided that the Plan does not have to reimburse for hearing aids (V5298) provided on June 21, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implants (D6011x6), the surgical placement of 
implant body (D6010x6), and the anesthesia (D9222). 
 
You asked the Plan to pre-approve the implants (D6011x6), the surgical placement of implant body (D6010x6), 
and the anesthesia (D9222). You say that the services are needing in order to eat in a proper way. You say this 
is a medical procedure and not dental. The Plan denied your request. The Plan says the services are not covered 
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. 
 
 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 
implants (D6011x6), the surgical placement of implant body (D6010x6), and the anesthesia (D9222).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable for transfer and 
clearly exceeds the CMS established defining criteria for an appropriate LTACH admission. The Plan denied 
your request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. 
 
 
 Our physician reviewer found the enrollee requires additional acute care services that can safely be provided at 
the current facility until more appropriate for transfer. There are no services at the LTACH that the enrollee 
requires that are not already available and covered at the current facility. Transfer to the LTACH would not be 
clinically advantageous at this time and completion of treatment at the current facility is recommended.  
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020).  
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested items are not a covered benefit for your 
condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the aspheric lenses provided on May 16, 2023. 
  
You asked the Plan to pay for the aspheric lenses. You say that you are appealing this denial. The Plan denied 
your request. The Plan says the service is not a covered benefit. 
 
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 standard lenses and frames. 
 
We looked at the file and the Plan's rules. Specifically, the aspheric lenses are considered upgrades. Based on 
this information, we decided that the Plan's rules for coverage of the aspheric lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for the aspheric lenses provided on May 16, 2023. 
  
Please note, the providers billing department advised that they have given you a discount for the denied lenses 
and reduced your responsibility from $80 to $38.10.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups, including any pins when required  
(D2950 x 2), pulp caps-indirect (excluding final restoration) (D3120 x 6), and an occlusal guard (D9944). 
 
You asked the Plan to pre-approve these items/services. You say that you are requesting a reconsideration of 
the Plan's denial. The Plan denied your request. The Plan says the requested items/services are not covered 
under the supplemental dental policy.  
 
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/services are not 
among those covered under this benefit.  
  
 
 
 
 
 
Therefore, we decided that the Plan does not have to pre-approve core buildups, including any pins when 
required (D2950 x 2), pulp caps-indirect (excluding final restoration) (D3120 x 6), and an occlusal guard 
(D9944).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve freestyle lite test strips. 
 
You asked the Plan to pre-approve the freestyle lite test strips. You say that the items should be covered as you 
disagree with the denial. 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 freestyle lite test strips. Therefore, we decided that the Plan does not have to pre-approve freestyle lite 
test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental service (D7953). 
 
You asked the Plan to pre-approve the dental service (D7953). You say that you would like to request 
reconsideration of the denied dental service and that the services requested are medically necessary. The Plan 
denied your request. The Plan says the service is not a covered 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 the 
dental service (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the implant supported porcelain/ceramic crowns (D6065 x 2) 
provided on May 30, 2023. 
 
You asked the Plan to pay for the dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental items provided are not covered 
under the supplemental dental policy.  
 
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 items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the implant supported 
porcelain/ceramic crowns (D6065 x 2) provided on May 30, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the surgical procedure (11900) and the triamcinolone injection (J3301) 
provided on July 19, 2023. 
 
You asked the Plan to pay for the surgical procedure (11900) and the triamcinolone injection (J3301). You say 
that  The Plan denied your request. The Plan says that injectable drugs are not covered without obtaining prior 
authorization. 
 
The Plan must follow Medicare rules. Your contract with the Plan says that certain services listed in the 
Medical Benefits Chart are covered only if your doctor or other network provider gets approval in advance. 
However, the contract says the prior approval requirement does not apply to out-of-network providers.  
 
We looked at the file and Medicare rules. The record shows you received services from an out-of-network 
provider. The Plans denial is based solely on the prior authorization requirement that applies to in-network 
providers. The EOC specifically states that you do not need to get approval in advance for out-of-network 
services. Based on this information, we decided that the Plan has to pay for the surgical procedure (11900) and 
the triamcinolone injection (J3301) provided on July 19, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the ambulance services and the emergency 
room visit provided on June 4, 2023. 
 
You asked the Plan to waive the copayments for the ambulance services and the emergency room visit. You 
say that you went by ambulance the second time to the emergency room, and they wheeled into the waiting 
room where you left after waiting. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. Also, it was verified with medical records that you were seen twice in the emergency room. 
  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 $180 
copayment for emergency ambulance per date of service regardless of the number of trips. emergency services 
and a $90 copayment for emergency services. You do not pay the emergency room visit cost share if you are 
admitted to the same hospital within 24 hours for the same condition.  
 
You have been asked to pay a $180 copayment the ambulance services and a $90 copayment for the emergency 
room visit. This item/service falls within the ambulance services and the emergency care benefit category. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayments for the ambulance services and the emergency room visit 
provided on June 4, 2023.