Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from January 18, 2023, to 
January 20, 2023. 
 
You asked the Plan to pay for the medication. You say that the medication was provided by the hospital. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for self-administered drugs provided 
from January 18, 2023, to January 20, 2023.  
 
Benefits for the medication 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 pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you are bed bound and without a shower chair 
with wheels, you are unable to access the shower. 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.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room (ER) services (80051, 82550, 82553, 
82565, 82947, 83874, 84484, 84520, 85025, 87804, 87811, 96372, 99284, J1885) provided on May 10, 2023. 
 
You asked the Plan to pay for the ER visit. 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 the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for emergency room (ER) services (80051, 
82550, 82553, 82565, 82947, 83874, 84484, 84520, 85025, 87804, 87811, 96372, 99284, J1885) provided on 
May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment  includes placement (D6057) 
and abutment supported porcelain / ceramic crown (D6058) provided on March 13, 2023. 
 
You asked the Plan to pay for custom fabricated abutment  includes placement and abutment supported 
porcelain / ceramic crown. You say that this is medically necessary. 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 pay for custom fabricated abutment  includes placement (D6057) and abutment supported porcelain / ceramic crown (D6058) 
provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mile limit. 
 
You asked the Plan to pre-approve additional transportation mile limit. You say that you do not agree that if the 
one way trip exceeds 50 miles, no service will be given. The Plan denied your request. The Plan says based on 
your 2023 EOC, you receive 48-one way non-emergency transportation trips per year. The Plan also says there 
is a 50 mile limit per trip. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 one-way non-emergency transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional transportation mile limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen equipment purchased on February 8, 2023. 
 
You asked the Plan to pay for the oxygen equipment. You say that your daughter purchased two machines one 
for your granddaughter and one for you. You say that you still owe money for your machine. The Plan denied 
your request. The Plan says the purchased oxygen equipment is not a covered benefit. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for the oxygen 
equipment purchased on February 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad (E0217) provided from 
January 5, 2023, to January 25, 2023. 
 You asked the Plan to pay for the water circulating heat pad. You say that you are appealing the denial with 
supporting documentation. The Plan denied your request. The Plan says the heating pad was 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 pay for the water circulating heat pad. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that a water heat pad is experimental and not clinically needed in this case. It has no 
proven effectiveness to benefit clinical outcomes. 
 
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 water circulating heat pad have not been met. Therefore, we decided that the 
Plan does not have to pay for the water circulating heat pad (E0217) provided from January 5, 2023, to January 
25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided from March 15, 2019, to 
December 16, 2021. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing amount 
when your services are received from an out-of-network provider.  
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for dental services provided from March 15, 
2019, to December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia  each subsequent 15-
minute increment (D9223). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. 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. Therefore, we decided that the Plan does 
not have to pre-approve deep sedation/general anesthesia  each subsequent 15-minute increment (D9223).
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 the CGM. You say that it is medically necessary for you to get a CGM 
because you are losing weight quickly. The Plan denied your request. The Plan says the Medicare criteria was 
not 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 you do not have diabetes. Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the panoramic radiographic image (D0330) provided on April 27, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that you have exceeded the allowable benefit 
for the service provided in this case.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plans contract states that one panoramic radiographic image is 
covered every three years. The Plan has stated that you have exceeded the allowable benefit for this service. 
However, the Plan has not provided evidence that demonstrates this service was previously provided and paid 
for by the Plan. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, 
we decided that the Plan has to pay for the panoramic radiographic image (D0330) provided on April 27, 2023.  
 
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 pre-approve the surgical placement of an implant body (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the Plan's decision 
since the crowns that are placed on your teeth are causing damage. You also say that your mouth is bleeding 
around that area. 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 July 24, 2023. Therefore, 
we decided that the Plan does not have to pre-approve the surgical placement of an implant body (D6010).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test provided on March 13, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that you are appealing the denial with supporting 
documentation. The Plan denied your request. The Plan says this test is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a Cxbladder test is not covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Cxbladder test have not been met. Therefore, we decided that the Plan does not have to pay for 
the Cxbladder test provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve re-examination of eyes and eyeglasses. 
 
You asked the Plan to pre-approve re-examination of eyes and eyeglasses. You say that you have double vision 
from the last pair of glasses you received. You also say that they are not acceptable for night driving. The Plan 
denied your request. The Plan says this benefit has been exhausted. 
 
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 one routine eye examination and one pair of eyeglasses per year. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers one routine eye examination 
and routine eyewear once every year. This benefit was exhausted on January 6, 2023. Based on this 
information, we decided that the Plan's rules for coverage of re-examination of eyes and eyeglasses have not 
been met. Therefore, we decided that the Plan does not have to pre-approve re-examination of eyes and 
eyeglasses.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that you have a hammertoe and fallen arches. You 
say that you need these orthotics. 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 pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical removal of erupted tooth (D7210) for tooth #3 
and #4 provided on May 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental services were done in the past couple 
of months and the Plan did not cover the dental services. The Plan denied your request. The Plan says the 
denial of payment for these services is correct, because the surgical removal of erupted tooth 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 
surgical removal of erupted tooth (D7210) for tooth #3 and #4 provided on May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) provided on 
March 13, 2023. 
 
You asked the Plan to pre-approve a mandibular partial denture (D5214). You say that you were previously 
approved for a partial payment. However, you were not able to have the work done at that time. You also say 
that you needed to get the replacement to relieve pain, and hope that you can pay the original price. The Plan 
denied your request. The Plan says this service is not a covered expense under the Plan. The Plan also says that 
the records indicate you did not contact the Plan prior to the date of service to verify benefit. 
 
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 
mandibular partial denture (D5214) provided on March 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraspinal chiropractic manipulative treatments  
(98943 x 3) provided from April 11, 2023, through May 23, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the extraspinal chiropractic manipulative treatments (98943 x 3) provided 
from April 11, 2023, through May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection device (E2311), an expandable 
controller (E2377), and an expandable controller harness (E2313). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that you are requesting reconsideration of 
the denied authorization. The Plan denied your request. The Plan says the upgraded electronics 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 the upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has sufficient strength and function in the upper extremities to 
manage standard power drive controls. 
 
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 an electronic connection device (E2311), an expandable controller (E2377), and 
an expandable controller harness (E2313).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. You say that the enrollee has a life-threatening 
condition that requires the use of this equipment. You say that to not have the requested equipment is a direct 
risk to the enrollee's life. 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 a home ventilator system is not medically necessary. Our physician reviewer found that although the 
enrollee has COPD and chronic respiratory failure there is no clear documentation to support a home ventilator. 
Also, there is no documented failure of BiPAP or BiPAP with AVAPS. 
 
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 a home ventilator system.
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 asking for a fast-tracked 
appeal for the denial of long-term acute care because their wound requires specialized care. You say the 
enrollee's situation is complex because defecating could impact their wound healing process. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare guidelines for care in an LTACH. 
 
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 the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. There are no services available at the LTACH that the enrollee requires that are 
not available at the health care setting being offered by the Plan. The Plan has approved ongoing care in the 
current acute care 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 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.