Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve an esophagogastroduodenoscopy (EGD) (43235). 
 
You asked the Plan to pre-approve an EGD. The Plan denied your request. The Plan says that recurring 
screenings of biopsy-negative short segments of the lower esophagus (such as is the case for this enrollee) are 
discouraged. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 an EGD. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee had an EGD on June 1, 2022, which was consistent with short-segment Barrett's, 
although biopsies were negative. A repeat EGD is medically necessary. Our reviewer found that even though 
biopsies were negative in 2022, the recommendation is to have a second EGD to confirm that this was not 
under-sampling of the esophagus. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an EGD have been met. Therefore, we decided that the Plan has to pre-approve 
an esophagogastroduodenoscopy (EGD) (43235).  
 
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 pontics (D6245) and the retainer crowns (D6740) for 
tooth #23, #24, #25, and #26 provided on April 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that crowns are a covered benefit, and you would 
have chosen different coverage if you knew that these types of crowns were not covered. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because prosthodontics is not covered 
by the 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 
pontics (D6245) and the retainer crowns (D6740) for tooth #23, #24, #25, and #26 provided on April 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 2, 2022, to 
February 16, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As more than 30 days passed between the timely filing date 
and the NOA receipt, no payment can be made on this claim. Therefore, we decided that the Plan does not have 
to pay for home health services provided from February 2, 2022, to February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 March 2, 2021. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extractions (D7210) for tooth #9, #10, and #11 
provided on April 3, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you got the extractions done so you could 
get your dentures and you were not aware that the Plan would only pay $1,000 for the dental services. 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 $1,000 for dental services on April 3, 2023; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of April 3, 2023. Therefore, we decided that 
the Plan does not have to pay more for the extractions (D7210) for tooth #9, #10, and #11 provided on April 3, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant (D4341), and periodontal scaling and root planing - one to three teeth per quadrant (D4342). 
 
You asked the Plan to pre-approve the periodontal scaling and root planing. The Plan denied your request. The 
Plan says these services are not covered. 
 
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 
periodontal scaling and root planing - four or more teeth per quadrant (D4341), and periodontal scaling and 
root planing - one to three teeth per quadrant (D4342).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nerve treatment on bicuspid tooth for tooth 20 (D3320). 
 
You asked the Plan to pre-approve nerve treatment . You say that this should be covered. The Plan denied your 
request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
nerve treatment on bicuspid tooth for tooth 20 (D3320).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 14, 2022. 
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. 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 June 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery (E1399). 
 
You asked the Plan to pre-approve a backup battery. You say that the item should be covered. The Plan denied 
your request. The Plan says a backup battery is considered an item of convenience and not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a backup battery (E1399).
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 inpatient rehabilitation is medically necessary. The 
Plan denied your request. The Plan says the enrollee's records do not show to have the endurance to participate 
in 3 hours of daily therapies. Services needed may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling completed in upper right, lower right and 
upper left quadrants (D4341) provided on November 22, 2021, to November 29, 2021. 
 
You asked the Plan to pay for periodontal scaling. You say that this was medically necessary. The Plan denied 
your request. The Plan says the records do not show bone loss or tartar buildup on the root surfaces of at least 4 
teeth. 
 
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 periodontal 
scaling 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 pay for periodontal scaling. Our reviewer says that the service is not medically necessary. Our physician reviewer found the upper right quadrant only has deep 
pocket depths recorded for teeth number 3,4. The lower right quadrant lists tooth 31 as the only tooth that has 
deep PDs. The upper left quadrant lists 13,14,15. The quadrants upper right, lower right, upper left does not 
meet the criteria for 4 or more teeth, therefore D4341 cannot be used. 
 
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 periodontal scaling have not been met. Therefore, we decided that the Plan does 
not have to pay for periodontal scaling completed in upper right, lower right and upper left quadrants (D4341) 
provided on November 22, 2021, to November 29, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on April 04, 2023. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing the claim payment denial. 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 physical therapy 
provided on April 04, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the chair (A9270). 
 
You asked the Plan to pre-approve the chair. You say that the item should be covered. The Plan denied your 
request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the chair (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3010).  
 
You asked the Plan to pay for foot orthotics. You say that you were treated with surgery for a torn tibial tendon 
and the foot inserts allow you to maintain an active life, caring for yourself and family. You also say that you 
have rheumatoid arthritis involving both feet but do not have diabetes. 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 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 pay for foot orthotics (L3010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on January 23, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration due to medical 
necessity. 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 the office visit provided 
on January 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hepatitis B vaccine provided on May 17, 2023. 
 
You asked the Plan to pay for hepatitis B vaccine. You say that it is medically necessary. The Plan denied your 
request. The Plan says the vaccine you received is covered under your Part D (pharmacy) benefits, not your 
medical benefits. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide hepatitis B vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to hepatitis B 
vaccine. Therefore, we decided that the Plan does not have to pay for hepatitis B vaccine provided on May 17, 
2023.  
 
Benefits for hepatitis B vaccine 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CPAP device provided from August 6, 2022, to April 6, 
2023, by an OON provider.  
 
You asked the Plan to pay for the CPAP device. You say that you did not know a prior authorization was 
needed. The Plan denied your request. The Plan says these services were not authorized. 
 
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 CPAP device provided from August 6, 2022, 
to April 6, 2023, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Xeomin injections for lower extremities. 
 
You asked the Plan to pre-approve the Xeomin injections for lower extremities. You say that the service is 
medically necessary. The Plan denied your request. The Plan says  Xeomin is not FDA approved for use in 
treatment of lower extremity spasticity. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Xeomin injections for lower 
extremities. Our reviewer says that the service is not medically necessary. Our physician reviewer found 
Xeomin is not FDA approved for use in treatment of lower extremity spasticity. Its use is not supported by one 
of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 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 Xeomin injections for lower extremities have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Xeomin injections for lower extremities.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve power wheelchair repairs and modifications (E1399). 
 
You asked the Plan to pre-approve power wheelchair repairs and modifications. You say that you are looking 
to see if your current wheelchair can be made smaller for you because it is too big. The Plan denied your 
request. The Plan says these repairs are being denied because you are unable to safely drive the power 
wheelchair. The Plan also says an item can only be approved if you are able to safely use it. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
 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 power wheelchair repairs and 
modifications. Our reviewer says that you do not meet the coverage criteria for the requested power wheelchair 
repairs and modifications. Our physician reviewer found you have damaged your wheelchair driving in parking 
lots and in your apartment. You do not follow safety rules based on the physical therapy evaluation, hitting bed 
frames repeatedly and leaving household objects in the wheelchair's path. Our reviewer also found that you are 
not safe driving the wheelchair and subjecting it to extensive wear and tear. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair repairs and modifications have not been met. Therefore, we 
decided that the Plan does not have to pre-approve power wheelchair repairs and modifications (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on April 7, 
2023, to April 10, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital care. 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 $372 
copayment per day for days 1-5 for inpatient hospital care.  
 
You have been asked to pay a $372 copayment per day for days 1-5 for inpatient hospital care. The total 
amount you are being asked to pay is $372 which is less than the required amount. This item/service falls 
within the inpatient hospital 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 copayment for 
inpatient hospital care provided on April 7, 2023, to April 10, 2023.