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

 
We decided that the Plan does not have to pre-approve the upgraded electronics.  
 
You asked the Plan to pre-approve the upgraded electronics. You say that the requested power wheelchair is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the notes do not show a 
medical need to control the power options through the 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 records document that the enrollee has three out of five bilateral 
upper extremity strength with pinch and grip rated as within functional limits and no reported contractures, 
fisting or poor dexterity, thus indicating the enrollee has adequate upper extremity strength and function to 
operate the wheelchair's power options with their own switches. Therefore, the reviewer found that the 
upgraded electronics are 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 the upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the upgraded electronics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller 
and two or more power seating system motors (E2311). 
 
You asked the Plan to pre-approve a wheelchair accessory. You say that you disagree with the denial and 
request reconsideration. The Plan denied your request. The Plan says the electronic connection cannot be 
covered as it is not medically necessary to control the two power options through the 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 a wheelchair accessory. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a past medical history including hereditary spastic paraplegia and has 
been authorized to have a group 3 power wheelchair with multiple options. The documentation indicates the 
enrollee is able to feed herself and has the strength to use the basic switches to operate the PWC. A group 3 
PWC can be covered if the medical necessity for a PWC is met and if the disorder causing the mobility 
limitation is a neurological condition, myopathy or congenital skeletal deformity.  The enrollee also must 
require a drive control interface, power tilt or a power recline seating system and if there has been a specialty 
evaluation that was performed by a licensed/certified medical professional, such as a physical or occupational 
therapist. An expandable controller is an electronic system that is capable of accommodating one or more 
additional features and can operate 3 or more powered seating options. The requested electrical accessories are 
not medically necessary as the enrollee does have use of the upper extremity and can operate and control the 
power options using the switches that are included in the basic wheelchair. 
 
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 wheelchair accessory have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection between wheelchair controller and two or more power 
seating system motors (E2311).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Aurora Spine ZIP interspinous fixation system and 
Spine Wave Tornado allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the requested Aurora Spine ZIP interspinous fixation system and Spine Wave Tornado allograft are considered experimental in nature. More 
research is needed to support their use. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an Aurora Spine ZIP interspinous fixation system and Spine Wave Tornado allograft.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2740 x 2) and core buildups (D2950 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that the criteria for coverage have 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 dental 
services when the services are medically necessary and reasonable. The Plans rules for coverage state that 
crowns are necessary when there is significant damage to the tooth caused by decay or fracture. Core buildup is 
provided when there is insufficient retention for a separate extracoronal restorative procedure. 
 
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 dental services. Our reviewer says 
that the request meets the criteria for coverage for core buildups (D2950) and crown restorations (D2740) for 
teeth number's 30 and 31. Our physician reviewer found that the documentation indicates the presence of 
defective alloy restorations and weakened enamel structure in teeth number's 30 and 31. It is medically 
reasonable to place core build ups and crown restorations to protect these teeth from fracture and to provide 
good masticatory function. 
 
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 dental services have been met. Therefore, we decided that the Plan has to 
pre-approve crowns (D2740 x 2) and core buildups (D2950 x 2).  
 
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: Favorable

 
We decided that the Plan has to pre-approve a vacuum-assisted suspension system (VASS) for a lower-limb 
prosthesis. 
 
You asked the Plan to pre-approve a VASS. You say that the requested item is a necessity for your care. The 
Plan denied your request. The Plan says that the requested item is experimental. 
 
The Plan follows Medicare rules. Medicare rules say that a lower limb prosthesis is covered when the 
beneficiary: 
1. Will reach or maintain a defined functional state within a reasonable period of time; and 
2. Is motivated to ambulate. 
 
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 VASS. Our reviewer says that a 
VASS is medically reasonable and necessary in this case. Our physician reviewer found that VASS is very 
much in the mainstream of standards of prosthetic care. Original Medicare would cover the entire requested replacement socket, the VASS, and all related addition codes in question given the medical record and the 
generally non-specific documentation requirements attached to the technology in question. 
 
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 VASS have been met. Therefore, we decided that the Plan has to pre-approve 
a vacuum-assisted suspension system (VASS) for a lower-limb prosthesis.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurostimulator implantation (63650).  

You asked the Plan to pre-approve neurostimulator implantation. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that spinal cord stimulators can be covered when specific 
criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve neurostimulator implantation. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does not 
have an approved indication for a spinal cord stimulator trial. The enrollee also has several other evidence-
based therapies available to her. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of neurostimulator implantation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve neurostimulator implantation (63650).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on January 06, 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 January 06, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the heart with 
evaluation of blood vessel calcium. 
 
You asked the Plan to pre-approve the CT scan of the heart. You say that the services are medically necessary.  
The Plan denied your request. The Plan says the services are not covered when used for screening purpose.  
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan of the heart. Our reviewer 
says that the CT scan is not medically necessary. Our physician reviewer found CT imaging of the heart 
without contrast material with quantitative evaluation of coronary calcium is considered experimental and 
investigational for the evaluation and management of this enrollee's medical condition. Therefore, the services 
cannot be approved. 
 
 
 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 CT scan of the heart have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a computed tomography (CT) scan of the heart with evaluation of blood vessel 
calcium.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on September 16, 2022. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that the enrollee 
should not have a copayment because the maximum out-of-pocket was met. 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 $100 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $100 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic test 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 enrollees $6,500 maximum out-of-pocket was not met at the time the 
service was rendered. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic 
resonance image (MRI) provided on September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontics (D6240 x 3) and retainer crowns (D6750 x 3). 
 
You asked the Plan to pre-approve the dental services. You say that you are not eating well and require these 
procedures. 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 authorization A0230424144565. 
Therefore, we decided that the Plan does not have to pre-approve pontics (D6240 x 3) and retainer crowns 
(D6750 x 3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2750 x 3) for tooth numbers 14, 19, 31. 
 
You asked the Plan to pre-approve the dental services. You say that you have a broken tooth and are in pain. 
You need these procedures approved. The Plan denied your request. The Plan says this service is not a covered 
benefit under your 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 pre-approve 
crowns (D2750 x 3) for tooth numbers 14, 19, 31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on 
February 23, 2023. 
  
You asked the Plan to pay for the dental services. You say that you verified that the provider was an in-network 
provider and the services 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 Plan's 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 for the intraoral radiographic image (D0220) on February 23, 2023; therefore, your benefit 
for the requested items or services was exhausted on the date of service of February 23, 2023. Therefore, we 
decided that the Plan does not have to pay for the intraoral radiographic images (D0230) provided on February 
23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography provided on February 27, 2023. 
 
You asked the Plan to pay for the fundus photography. You say that you are appealing the $20 copayment for 
the fundus photography. The Plan denied your request. The Plan says the service is not a covered supplemental 
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 is not a covered supplemental benefit. 
 
We looked at the file and the Plan's rules. Specifically, the record shows a routine refraction diagnosis which 
means you do not meet Medicare coverage criteria. Also, the service is not a covered supplemental benefit. 
Based on this information, we decided that the Plan's rules for coverage of the fundus photography have not 
been met. Therefore, we decided that the Plan does not have to pay for the fundus photography provided on 
February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid (V5261), purchased on October 31, 2022. 
 
You asked the Plan to pay for the hearing aid. You say that the item should be covered. The Plan denied your 
request. The Plan says this is not a Plan preferred hearing aid. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays a $500 
allowance toward the Plan's preferred brand hearing aid. Hearing aids that are not the Plan's preferred brand are 
not covered. 
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the 
hearing aid (V5261), purchased on October 31, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675). 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says pneumatic compression devices are not covered for 
preventative services. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 9, 2023. 
 
You asked the Plan to pay for the lab services. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says you billed with an incorrect place of service on the 
claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on February 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unspecified periodontal treatment (D9999). 
 
You asked the Plan to pre-approve unspecified periodontal treatment. You say that this is medically necessary. 
The Plan denied your request. The Plan says not medically necessary as following the plan's criteria for 
periodontal treatment, the following must be met for a service to be covered: 
-A minimum of four (4) teeth affected in the quadrant. Periodontal charting indicating abnormal pocket depths 
in multiple sites. 
- Additionally, at least one of the following must be present: 
1) Radiographic evidence of root surface calculus. 
2) Radiographic evidence of noticeable loss of bone support. 
 
The treating dentist provided additional information for the appeal review. The records did not meet the above 
criteria.  
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 unspecified 
periodontal treatment 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 unspecified periodontal treatment. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the reason for the 
denial was that the documentation was not complete. A review of the documentation did not specify what 
treatment was supplied. There was no narrative submitted nor was there a procedure code describing the 
treatment. 
 
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 unspecified periodontal treatment have not been met. Therefore, we decided 
that the Plan does not have to pre-approve unspecified periodontal treatment (D9999).