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

 
We decided that the Plan has to pre-approve surgical placement of implant body: endosteal implant tooth #13 
(D6010). 
 
You asked the Plan to pre-approve the surgical placement of implant body. You say that the enrollee has a 
good implant predictability based on their dental history. You also say that the implant on #13 represents a 
continuation of the presented dental treatment plan per the enrollee's agreement and expectations. The Plan 
denied your request. The Plan says that coverage criteria for the dental service has not been met. 
 
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 surgical 
placement of implant body 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 surgical placement of implant body. 
Our reviewer says that the dental service is medically necessary. Our physician reviewer found from the x-ray, 
that tooth 14 has drifted forward in the mouth, tooth 13 is missing. It is hard to examine the bone levels for an 
implant with the x-ray submitted, but from the x-ray it does look like there is bone in the area. The plan for the 
type and size of implant placed can ultimately be determined by the provider. The provider is stating that the 
enrollee will have a good outcome based on their dental history. Based on the information included, D6010 is 
medically reasonable and necessary. An implant on tooth 13 area will also allow the enrollee to chew equally 
on both sides of the mouth, and this will less the discomfort on the right side of the jaw.  
 
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 surgical placement of implant body have been met. Therefore, we decided 
that the Plan has to pre-approve surgical placement of implant body: endosteal implant tooth #13 (D6010).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the continued use of a home ventilator system. 
 
You asked the Plan to pre-approve the home ventilator system. You say that without non-invasive ventilation 
therapy the enrollee is at risk of readmission to the hospital or even death. The Plan denied your request. The 
Plan says a home ventilator is not medically necessary for this patient because their needs can be met with an 
alternative device such as a BiPAP device with average volume-assured pressure support (AVAPS).   
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 system. Our reviewer 
says that the continued use of a home ventilator system is not medically necessary. Our physician reviewer 
found that the enrollee was started on ta home ventilator in July of 2022. However, the records do not include 
documentation of chronic carbon dioxide retention with an arterial blood gas done while stable. Also, there is 
no diagnosis of COPD, thoracic restrictive disease, or neuromuscular disease. Additionally, a device download 
covering June 20, 2023, to July 19, 2023, showed the enrollee is using the device more than 4 hours a day for 
0% of days, which is not enough use to expect benefit. Therefore, the continuation of the home ventilator is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home ventilator system. have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the continued use of a home ventilator system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on June 27, 2023. 
 
You asked the Plan to pay for a home visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
June 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on June 23, 2023. 
 
You asked the Plan to pay for a home visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
June 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on July 10, 2023. 
 
You asked the Plan to pay for an office visit. You say that the services rendered were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on July 10, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Yervoy. 
 
You asked the Plan to pre-approve the drug. The Plan denied your request. The Plan says that Yervoy is not 
medically necessary.  
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 drug. Our reviewer says that Yervoy 
is medically necessary. Our physician reviewer found that the requested use of Yervoy is FDA-approved. 
Yervoy is also safe and effective and otherwise reasonable and necessary 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 the drug have been met. Therefore, we decided that the Plan has to pre-approve 
Yervoy.  
 
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: 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 a continuous glucose monitor (CGM). You say that the requested item is 
medically necessary even though you do not take insulin because your prior clinical blood test shows that your 
sugar levels go up and down and they are not regulated. The Plan denied your request. The Plan says the 
criteria for approval have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia Based on this information, we decided that Medicare rules for 
coverage of a continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion or replacement of the Optimizer Smart 
permanent cardiac contractility modulation system (0408T). 
 
You asked the Plan to pre-approve the insertion or replacement of the Optimizer Smart permanent cardiac 
contractility modulation system. You say that this is a non-experimental, payable service. The Plan denied your 
request. The Plan says the Medicare guidelines say that this item or service is not medically necessary because 
a scientific assessment of the technique has not been completed and its safety and efficacy has not been 
established. 
 
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 insertion or replacement of the 
Optimizer Smart permanent cardiac contractility modulation system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that while clinical studies have led to Food and Drug Administration (FDA) approval in 2019, the 
Optimizer Smart permanent cardiac contractility modulation system remains the subject of multiple studies 
examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical 
efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes 
and benefit. The requested service is not considered medically reasonable and necessary at this time. 
 
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 insertion or replacement of the Optimizer Smart permanent cardiac 
contractility modulation system have not been met. Therefore, we decided that the Plan does not have to pre-
approve the insertion or replacement of the Optimizer Smart permanent cardiac contractility modulation system 
(0408T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #7 provided on June 19, 
2023. 
 
You asked the Plan to pay more for the dental service. You say that your provider told you that they would not 
go over the Plan's benefit allowance. The Plan denied your request. The Plan says your annual dental maximum 
benefit for the year 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 the Plan paid $223 for dental services on May 12, 2023. On June 2, 2023, the Plan paid $3,196 for 
dental services. On June 23, 2023, the Plan paid $581 for dental services. For the year of 2023 the Plan paid 
$4,000 ($223 paid + $3,196 paid + $581 paid) for dental services; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of June 19, 2023. Therefore, we decided that 
the Plan does not have to pay more for a crown (D2740) for tooth #7 provided on June 19, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Kerecis Omega3 (Q4158). 
 
You asked the Plan to pre-approve Kerecis Omega3. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 Kerecis Omega3. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, per Medicare guidelines, the request is not medically necessary because 
the records do not show that this skin substitute (Kerecis Omega3), will be used to treat a chronic wound that 
has failed comprehensive wound therapy over a period of at least 30 days. In addition, usage of the Kerecis Omega3 skin substitute in MMS reconstruction is not considered the standard of care. The review has 
determined that the items/services at issue in this case 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 Kerecis Omega3 have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Kerecis Omega3 (Q4158).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on April 26, 2023. 
 
You asked the Plan to pay for a home visit. You say that the enrollee should not have needed a referral or 
authorization. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit provided on 
April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite (D2332) for tooth #6 and to 
pay for the resin-based composite (D2331, D2332, D2392) for tooth #2, #10, and #11 and a crown (D2750) for 
tooth #19 provided on May 1, 2023, May 2, 2023, and May 8, 2023. 
 You asked the Plan to pay more for the dental services. You say that the dental services were approved so they 
should be paid. The Plan denied your request. The Plan says your annual dental maximum benefit for the year 
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 the Plan paid $104 for dental services on January 17, 2023. On March 1, 2023, the Plan paid $2,118 for 
dental services. On April 6, 2023, the Plan paid $675 for dental services. On April 12, 2023, the Plan paid $675 
for dental services. On April 13, 2023, the Plan paid $304 for dental services. On May 1, 2023, the Plan paid 
$124 for dental services. For the year of 2023 the Plan paid $4,000 ($104 paid + $2,118 paid + $675 paid + 
$675 paid + $304 paid + $124 paid) for dental services; therefore, your annual dental maximum benefit for the 
year of 2023 was exhausted on the date of service of May 1, 2023. Therefore, we decided that the Plan does not 
have to pay more for the resin-based composite (D2332) for tooth #6 and to pay for the resin-based composite 
(D2331, D2332, D2392) for tooth #2, #10, and #11 and a crown (D2750) for tooth #19 provided on May 1, 
2023, May 2, 2023, and May 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient home visit, and advance care planning services 
provided on May 08, 2023. 
 
You asked the Plan to pay for a new patient home visit, and advance care planning services. You say that these 
services were medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a new patient home 
visit, and advance care planning services provided on May 08, 2023.
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 lives alone and needs round-the-clock 
care which family cannot provide. The Plan denied your request. The Plan says the SNF care is not medically 
necessary, and the enrollee's needs can be met 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 does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. 
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on June 15, 
2023. 
 
You asked the Plan to pay for the periodontal maintenance. You say that this procedure is necessary because it 
is a follow-up to a procedure code 4341, gum disease treatment. The Plan denied your request. The Plan says 
this procedure is not a benefit under the dental 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 pay for the 
periodontal maintenance (D4910) provided on June 15, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of the LinQ SI Joint Stabilization System 
(0775T). 
 
You asked the Plan to pre-approve placement of the LinQ SI Joint Stabilization System. You say that the 
enrollee has been in pain for years. The Plan denied your request. The Plan says the enrollee has documentation 
of other obvious sources of pain to the lower back, there is no documentation of the required 3 provocative 
tests, and imaging studies of the lumbar spine document other causes of the pain. Additionally, at the time of 
this review, the LinQ SI stabilization device remains experimental, and more research is needed to show safety 
and efficacy. 
 
The Plan follows Medicare rules. Medicare rules say that this procedure is covered when the coverage criteria 
listed in the Medicare rules section of this letter 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 placement of the LinQ SI Joint 
Stabilization System. Our reviewer says that the service is not medically necessary. Our physician reviewer 
found that the enrollee does not meet these criteria with respect to diagnostic maneuvers and that this is 
considered experimental at this time. Therefore, the request is deemed not medically necessary and 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 placement of the LinQ SI Joint Stabilization System have not been met. 
Therefore, we decided that the Plan does not have to pre-approve placement of the LinQ SI Joint Stabilization 
System (0775T).