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

 
We decided that the Plan does not have to pre-approve unspecified removable prosthodontic procedure, by 
report (D5899). 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services. The Plan 
denied your request. The Plan says this service is not covered under your 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. Unspecified removable 
prosthodontic procedure, by report is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5899 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve unspecified 
removable prosthodontic procedure, by report (D5899).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse Generator 
(0408T). 
 
You asked the Plan to pre-approve an Optimizer Smart Implantable Pulse Generator (0408T). You say that the 
requested Optimizer Smart Implantable Pulse Generator (0408T) is medically necessary. The Plan denied your 
request. The Plan says the requested Optimizer Smart Implantable Pulse Generator (0408T) 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 an Optimizer Smart Implantable Pulse 
Generator (0408T). Our reviewer says that the requested Optimizer Smart Implantable Pulse Generator 
(0408T) is not medically necessary. Our physician reviewer found the current medical literature pertaining to the cardiac contractility modulation (CCM) system confirms multiple observational studies suggesting clinical 
benefit from CCM. Several randomized clinical trials of CCM versus control have also been reported, along 
with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in 
quality-of-life scores and objective functional capacity. While the clinical studies led to Food and Drug 
Administration (FDA) approval in 2019, CCM 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. At the 
current time, the CCM system is not medically necessary for this 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 an Optimizer Smart Implantable Pulse Generator (0408T) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an Optimizer Smart Implantable Pulse 
Generator (0408T).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic and retainer crown (D6750, D6240). 
 
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 you do 
not meet the clinical requirements to be approved. 
 
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 a 
pontic and retainer crown (D6750, D6240).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you have Parkinson disease, myasthenia gravis and 
myositis that needs acute rehabilitation. The Plan denied your request. The Plan says your condition does not 
meet all of the requirements for inpatient rehabilitation, services 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: 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 receiving appropriate in-
patient acute care and does not require transfer to a Long-Term Acute Care Hospital. The Plan denied your 
request. The Plan says admission the long-term acute care and will allow the enrollee to receive care and able 
to meet all of needs and provide the best ability to maximum function, and stable for transfer. 
 
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 there are no services available at the LTACH that the enrollee requires that are not 
available at the current health care setting being offered by the health plan.  
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 07, 
2022. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the 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 subsequent nursing 
facility care provided on October 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued care with an out-of-network (OON) urologist. 
 
You asked the Plan to pre-approve continued care with an OON urologist. You say that the continued care with 
the out-of-network urologist is medically necessary. The Plan denied your request. The Plan says the continued 
care with the out-of-network urologist is not medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 continued care with an OON 
urologist. Our reviewer says that the continued care with the out-of-network urologist is not medically 
necessary. Our physician reviewer found the record indicates that the enrollee has urinary incontinence in the 
setting of overactive bladder. The record provided does not establish that the enrollee requires emergent or 
urgent care or that he is receiving active treatment such that transferring his care and medical management to 
another provider would be medically inappropriate and/or contraindicated at this time. The elements of the 
coverage criteria are not satisfied. The requested service is not 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 continued care with an OON urologist have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued care with an out-of-network (OON) urologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision care provided on February 16, 2023. 
 
You asked the Plan to pay for vision care. You say that this service is supported in the records. 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 vision care provided on 
February 16, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial nursing facility care provided on January 11, 2023. 
 
You asked the Plan to pay for initial nursing facility care. You say that the 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 initial nursing facility 
care provided on January 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor. 
 
You asked the Plan to pre-approve the Dexcom G6 continuous glucose monitor. You say that you are appealing 
the medical necessity denial for the CGM and supplies due to other general symptoms and signs. The Plan 
denied your request. The Plan says you do not require insulin three or more times daily. 
 
 
 
 The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the you do not use insulin with at 
least three daily injections. Based on this information, we decided that Medicare rules for coverage of the 
Dexcom G6 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G6 continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
 
  While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the arthrocentesis provided on December 
19, 2022. 
 
You asked the Plan to waive the copayment for the arthrocentesis. You say that you have had this procedure 
before and have never been charged this amount. 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 $200 
copayment for in-network outpatient surgery. 
 
You have been asked to pay a $200 copayment for the arthrocentesis. This item/service falls within the in-
network outpatient surgery 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 the 
arthrocentesis provided on December 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each ambulance transportation provided on 
August 02, 2022. 
 
You asked the Plan to waive the copayment for each ambulance transportation. You say that you say 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 $260 
copayment for ambulance Services.  
You have been asked to pay a $260 copayment for each ambulance transportation. This item/service falls 
within the ambulance Services 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. The total amount you owe is $520 ($260 copayment x 2 trips = $520.) 
Therefore, we decided that the Plan does not have to waive the copayment for each ambulance transportation 
provided on August 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sinus augmentation via a vertical approach (D7952). 
 
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 sinus 
augmentation via a vertical approach (D7952).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6549. 
 
You asked the Plan to pre-approve the compression stockings. You say that you have been getting these 
compression stockings for at least 10 years. You also say that you've never experienced a problem like this 
before where they consider them not covered. The Plan denied your request. The Plan says you do not have a 
qualifying wound for coverage of compression stockings. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with multiple power 
options (K0861) and related features/accessories. 
 You asked the Plan to pre-approve a group 3 PWC with multiple power options and related 
features/accessories.. You say that the items are medically necessary. The Plan denied your request. The Plan 
says the items are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a group 3 PWC with multiple power options is 
covered when the criteria listed in the Medicare Rules section is met. If the base PWC is denied all related 
accessories will be denied as not 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 group 3 PWC with multiple power 
options and related features/accessories. Our reviewer says that the member does not need these items. Our 
physician reviewer found the provided records do not support that the patient is high risk for skin breakdown 
(she reportedly performs stand-pivot transfers with supervision), has a history of pressure ulcer(s) or has had 
skin flap surgery. Records do not document the patient performs bladder self-catheterization and is unable to 
transfer independently or that the patient has increased muscle tone or spasticity to meet criteria for the power 
tilt and/or recline. Thus, the multiple power option wheelchair base does not meet criteria. As the wheelchair 
base does not meet criteria, the requested accessories are not covered. 
 
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 PWC with multiple power options and related features/accessories. 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power 
wheelchair (PWC) with multiple power options (K0861) and related features/accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care provider (PCP) office visit 
provided on November 16, 2022. 
 
You asked the Plan to waive the copayment for the PCP office visit. You say that this was an annual wellness 
visit. 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 $25 
copayment for in-network primary care provider office visits.  
 
The record shows this claim was approved and you are responsible for the cost share amount. You have been 
asked to pay a $25 copayment for the PCP office visit. This item/service falls within the in-network primary 
care provider office visits 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 the primary 
care provider (PCP) office visit provided on November 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care provider office visit 
provided on December 09, 2022. 
 
You asked the Plan to waive the copayment for the primary care provider office visit. You say that you 
eventually left after waiting a long time, and were never seen by the provider. 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 $10 
copayment for in-network primary care physician/practitioner services. 
 
You have been asked to pay a $10 copayment for the primary care provider office visit. This item/service falls 
within the in-network primary care physician/practitioner services 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. The record shows this claim was approved and you 
are responsible for the cost share amount. Therefore, we decided that the Plan does not have to waive the 
copayment for the primary care provider office visit provided on December 09, 2022.