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

 
We decided that the Plan does not have to pay for skilled nursing facility provided on February 22, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you would like a 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 skilled nursing facility 
provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of an implant body: endosteal 
implants for teeth number 18, 19, 30 and 31 (D6010 x 4).  
 
You asked the Plan to pre-approve these dental items/services. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says the requested dental 
item/services are not covered under your supplemental dental policy.  
 
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/services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of an implant body: endosteal implants for teeth number 18, 19, 30 and 31 (D6010 x 4).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on 
March 10, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were rendered by an out-of-network provider, without prior authorization.  
 
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 issue reimbursement for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue.   
 
 
We found no exception that would require the Plan to issue reimbursement for these items. Therefore, we 
decided that the Plan does not have to issue reimbursement for the hearing aids (V5261) purchased on  
March 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that you have over 13 
different doctors you need to see and need assistance getting to your appointments.  The Plan denied your request. The Plan says as of June 13, 2023, you have used or scheduled 100 one-way 
trips. Your 100 trips may include some trips that you have already scheduled but not yet used. The request for a 
101 trip and beyond is not a covered benefit.  
 
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 100 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips for your doctor appointments. 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 routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ozempic. 
 
You asked the Plan to pre-approve Ozempic. The Plan denied your request. The Plan says the requested drug is 
not covered under Part B due to lack of Buy and Bill. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Ozempic.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 17, 2023. 
 
You asked the Plan to pay for an office visit. You say that these services were medically necessary. The Plan 
denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for an office visit provided 
on February 17, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital outpatient visit to be provided on by an out-
of-network (OON) provider.  
 
You asked the Plan to pre-approve a hospital outpatient visit. You say that you had a surgery last year and need 
to have a second appointment. The Plan denied your request. The Plan says there are in-network providers 
available for this service. 
 
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 has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a hospital outpatient visit to be provided on by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician services to be provided by a tertiary provider.  
 
You asked the Plan to pre-approve the requested services. You say that network providers have not been 
helpful. The Plan denied your request. The Plan says the services can be provided by network specialists. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The file shows that a tertiary (advanced) provider was requested for knee pain. The Plan has community 
network providers available who can provide the services at issue in this appeal. We found no exception that 
would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-
approve physician services to be provided by a tertiary provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) for 
tooth #18, #19, #30, and #31. 
 
You asked the Plan to pre-approve the dental services. You say that you have full coverage, and all the 
information was submitted but the provider insist that you do not have implant coverage. The Plan denied your 
request. The Plan says the denial of authorization for these services is correct, because dental implants and all 
associated services are 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 pre-approve the 
surgical placement of implant body (D6010) for tooth #18, #19, #30, and #31.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 800 additional units of Botox. 
 
You asked the Plan to pre-approve the additional Botox. You say that the additional units are medically 
necessary. The Plan denied your request. The Plan says 1600 units have already been approved. Additional 
units are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise 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 the additional Botox. Our reviewer says 
that the additional units requested are not medically necessary. Our physician reviewer found the record 
indicates that the enrollee has a diagnosis of  post stroke spasticity. The Food and Drug Administration has not 
stated that the requested dosage is indicated for the enrollee's condition. The Medicare approved drug 
compendia do not contain a supportive citation for the use of the requested dosage for the enrollee's condition. 
 
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 additional Botox have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 800 additional units of Botox.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deep sedation (D9222 and D9223) provided on February 
23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay the bill. The Plan 
denied your request. The Plan says the denial of payment for these services is correct, because thedeep sedation 
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 deep 
sedation (D9222 and D9223) provided on February 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair (K0848) and 
additional items and accessories (codes E0973, E2361, E1028, E2622, and K0040). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the enrollee qualifies for a group 3 power wheelchair. The Plan denied your request. The Plan 
says the enrollee does not have medical need for single power options included with group 3 power wheelchair. 
 
 
 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 a group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the group 3 power wheelchair is not medically 
necessary. Our physician reviewer found the enrollee has Parkinsons Disease and is functionally non-
ambulatory. The enrollee cannot use a cane or walker for mobility and is at risk for falling. Our reviewer found 
that the enrollee cannot functionally propel a manual wheelchair due to upper extremity weakness and lack of 
coordination. The enrollee cannot operate a power scooter due to impaired sitting balance. Our physician 
reviewer found that the enrollee requires a power wheelchair for mobility and accomplishing their daily 
activities. However, the clinical documentation is insufficient why a lower-level power wheelchair would not 
suffice for their needs versus a group 3 power wheelchair. Our reviewer also found that the enrollee may 
require power tilt for a moderate risk for skin breakdown, but there is no requirement for power tilt and recline 
or power elevating leg rests. This can be accomplished with group 2 power wheelchair and does not require the 
complexity of a group 3 power wheelchair base which accommodates multiple power options. 
 
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 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair (K0848) and additional items and accessories (codes E0973, E2361, E1028, E2622, and K0040).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a flex-walk style foot (L5981, a K3 component) with multi-axial 
ankle and active dorsiflexion (L5968).  
 
You asked the Plan to pre-approve a flex-walk style foot with multi-axial ankle and active dorsiflexion . You 
say that the items are medically necessary. The Plan denied your request. The Plan says that the items are not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient 
clinical documentation of functional need for the technologic or design feature of a given type of foot. This 
information must be retained in the treating practitioner's or prosthetist's files. 
 
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 flex-walk style foot with multi-axial 
ankle and active dorsiflexion. Our reviewer says that the enrollee does need these items. Our physician 
reviewer found the enrollee is a K3 ambulator and entitled to this class of componentry. 
 
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 flex-walk style foot with multi-axial ankle and active dorsiflexion have been 
met. Therefore, we decided that the Plan has to pre-approve a flex-walk style foot (L5981, a K3 component) 
with multi-axial ankle and active dorsiflexion (L5968).   
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee does not meet all the 
requirements for admission to 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 that there are no services at the LTACH that the patient requires that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of extracranial arteries (93880) and 
duplex scan of extremity veins (93970) to be rendered by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a duplex scan of extracranial arteries and duplex scan of extremity veins. 
You say that it is best to do the services at the requested location since the referring doctor is from this location 
and information will be readily available for your heart surgery. The Plan denied your request. The Plan says 
your medical group has approved the test you need at a network radiology facility instead of the specialized 
center that was requested. The test will be performed by similarly qualified personnel using similar equipment 
and the results will be available to the provider who ordered it. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
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 a duplex scan of extracranial arteries 
and duplex scan of extremity veins. Our reviewer says that this request is not medically necessary. Our 
physician reviewer found the requested ultrasound exams are routine and can be performed at an in-network 
provider. Our reviewer also found that not only can the reports be transmitted electronically, but the actual 
images can be transferred to a compact disc or thumb drive and can then be viewed by the surgical team 
without any delay. 
 
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 duplex scan of extracranial arteries and duplex scan of extremity veins have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan of extracranial 
arteries (93880) and duplex scan of extremity veins (93970) to be rendered by an out-of-network (OON) 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from July 7, 2023, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from July 7, 2023, forward. You say that the 
services are medically necessary. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from July 7, 
2023, forward. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
enrollee did not require inpatient/detoxification beyond July 7, 2023, as he was not showing any withdrawal 
symptoms or any medical issues and was not a danger to himself or others, did not have any delusions or 
auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in 
question. It did not appear that the services for the dates in question were reasonably expected or medically 
necessary to improve the patients condition or for the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from July 7, 2023, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from July 7, 2023, 
forward.