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

 
We decided that the Plan has to pre-approve a Group 3 power wheelchair with multiple power options 
(tilt/recline, legrests, seat elevator) and accessories. 
 You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that the 
enrollee is no longer able to ambulate or propel a manual wheelchair. You say that the enrollee is home alone 
for 4 to 6 hours per day with the inability to complete any form of pressure relief. You also say that the 
enrollee's strength and function are deteriorating. The Plan denied your request. The Plan says that the enrollee 
does not have a medical need for the requested power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria have been 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 a Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is medically necessary. Our physician reviewer found the provided documentation indicates the 
enrollee is functionally non-ambulatory and cannot use a cane or walker for mobility due to weakness and high 
risk for falling. They cannot functionally propel a manual wheelchair due to upper extremity weakness. The 
enrollee requires power tilt and recline since they currently cannot adequately perform pressure relief due to 
upper extremity weakness and this will become worse with the progression of the enrollees amyotrophic 
lateral sclerosis (ALS). The enrollee is noted to have lower extremity spasticity that would necessitate a power 
elevating foot platform. This is also needed for positioning. The enrollee requires assistance and supervision 
with transfers and therefore would benefit from a power seat elevator to increase their level of independence 
with transfers. The enrollee has a neuromuscular disease that would benefit from a Group 3 power wheelchair 
base. Therefore, the requested Group 3 power wheelchair with power tilt and recline, power seat elevator and 
power elevating footrests are 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 a Group 3 power wheelchair with multiple power options have been met. 
Therefore, we decided that the Plan has to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, legrests, seat elevator) and accessories.  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired 
computed tomography (CT) scan (78815). 
 
You asked the Plan to pre-approve a PET/CT scan. The Plan denied your request. The Plan says that the 
request does not meet the Medicare or health plan coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 a PET/CT scan. Our physician reviewer 
found given that the lymph nodes being followed with imaging are not enlarged but based on metabolic activity 
detected on PET scan to check for recurrence, a PET scan in this case is medically reasonable. 
 
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 PET/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan 
(78815).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision item, the polycarbonate lens, the ultraviolet (UV) 
lens, and the antireflective coating provided on June 7, 2023. 
 
You asked the Plan to pay for the vision items. You say that you had a stroke in 2016 which affected your 
vision.  The Plan denied your request. The Plan says the services are not covered benefits. 
 
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 covers basic lenses and frames. 
 
We looked at the file and the Plan's rules. Specifically, the services are considered upgrades and are not 
covered services. Based on this information, we decided that the Plan's rules for coverage of the vision items 
have not been met. Therefore, we decided that the Plan does not have to pay for the vision item, the 
polycarbonate lens, the ultraviolet (UV) lens, and the antireflective coating provided on June 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite for one posterior surface (D2391) 
provided on June 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that your previous dentist did not fill the cavity on 
tooth 31 on February 2, 2023. You also say you went to another dentist on June 26, 2023, and had the tooth 
filled. 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 February 2, 2023. 
Therefore, we decided that the Plan does not have to pay for a resin-based composite for one posterior surface 
(D2391) provided on June 26, 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. The Plan denied your request. The Plan says the request 
for a home mechanical ventilator set in intelligent volume-assured pressure support (iVAPS) mode with Auto-
expiratory positive airway pressure (EPAP) that could be delivered by BiPAP is not covered. 
 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 criteria for coverage have not been met. Our physician reviewer found the record indicates that the 
enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that 
the enrollee was successfully treated with BiPAP. Our reviewer found that the provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with AVAPS capability and failure of such a 
device has not been documented. Our physician reviewer also found that the Plan has indicated coverage for 
such a device is available upon request. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Self-Administered Drugs. 
 
You asked the Plan to pay for 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 pay for Self-Administered Drugs.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your denture and need a 
replacement. The Plan denied your request. The Plan says that your benefit for the requested item or service 
has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve a mandibular partial denture (D5214).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth consultation provided on April 18, 2023. 
 
You asked the Plan to pay for a telehealth consultation. You say that the enrollee was in a nursing home at the 
time the service was rendered. 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 telehealth consultation 
provided on April 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services without transport received on 
October 30, 2022. 
 
You asked the Plan to pay for the ambulance services without transport. You say that the services were 
medically necessary. 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 October 30, 2022. 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 the ambulance services without transport received 
on October 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
April 27, 2023, to May 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told they accepted your insurance. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network provider on April 27, 2023, to May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), progressive lenses (V2781), polarization 
(V2762), and anti-reflective coating (V2750) provided on July 18, 2023. 
 
You asked the Plan to pay for frames (V2020), progressive lenses (V2781), polarization (V2762), and anti-
reflective coating (V2750). You say that you purchased a pair of sunglasses as their old prescription expired. 
You also say that you are requesting a reimbursement of $200.00 per their coverage. The Plan denied your 
request. The Plan says you do not have out-of-network benefits under the Plan vision 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 when you obtain your eyewear from Plan vision providers who are in-
network.. 
 
We looked at the file and the Plan's rules. The Plan rules say that you are responsible for all eyewear costs from 
providers outside of the Plan vision network. Based on this information, we decided that the Plan's rules for 
coverage of frames (V2020), progressive lenses (V2781), polarization (V2762), and anti-reflective coating 
(V2750) have not been met. Therefore, we decided that the Plan does not have to pay for frames (V2020), 
progressive lenses (V2781), polarization (V2762), and anti-reflective coating (V2750) provided on July 18, 
2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a harness for upgrade to expandable controller (E2313) 
and an expandable controller (E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says it is not medically necessary for the power options to be 
controlled through a joystick. 
 
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 the upgraded electronics. Our reviewer 
says that the requested upgraded electronics are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation does not reveal that the enrollee has 3 or more 
power options on the approved wheelchair. The documentation does not reveal that the enrollee is unable to control any power options with their own switches. The documentation does not reveal that the enrollee needs a 
specialized steering device such as a head switch. Therefore, the reviewer found that the requested upgraded 
electronics are 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a harness for upgrade to expandable controller (E2313) and an expandable 
controller (E2377).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 28 additional routine transportation trips. 
 
You asked the Plan to pre-approve additional transportation.. You say that you have dialysis that is keeping you 
alive. The Plan denied your request. The Plan says you have exceeded your benefit. 
 
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 24 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 28 additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OTC women's supplements provided on May 14, 2022. 
 
You asked the Plan to pay for the OTC women's supplements. You say that you are requesting reimbursement 
for the items. You say you were unaware that there was a deadline to submit for reimbursement. The Plan 
denied your request. The Plan says the service does not fall within the eligible benefit period. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested items are not among 
those covered under this benefit. Specifically, the claim was submitted on June 29, 2023, which was past the 
deadline. Therefore, we decided that the Plan does not have to pay for the OTC women's supplements provided 
on May 14, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a breast tomosynthesis and a mammogram 
provided on May 30, 2023. 
 
You asked the Plan to waive the deductible for a breast tomosynthesis and a mammogram. You say that the 
diagnostic service should be covered under the preventative service. 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 $400 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
 
 You have been asked to pay $22.23 towards your deductible for the breast tomosynthesis. You have also been 
asked to pay $80.94 towards your deductible for the mammogram. The item or service you asked the Plan to 
waive the deductible for falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 
deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing 
is a contractual obligation that had not been met at the time a breast tomosynthesis and a mammogram was 
received on May 30, 2023. Therefore, we decided that the Plan does not have to waive the deductible for a 
breast tomosynthesis and a mammogram provided on May 30, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xtandi capsules. 
 
You asked the Plan to pre-approve Xtandi. 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 Xtandi capsules.   
Benefits for Xtandi may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient office visit provided on July 11, 2023. 
 
You asked the Plan to pay for a new patient office visit. You say that this service was 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 a new patient office visit 
provided on July 11, 2023.