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

 
We decided that the Plan does not have to pay for non-urgent ambulance transport to and from the enrollees 
residence to the physicians office. 
 
You asked the Plan to pay for non-urgent ambulance transport to the physicians office.. You say that the 
services were medically necessary for the enrollee due to their condition. The Plan denied your request. The 
Plan says the ambulance transport to or from an outpatient office is not a Medicare covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when 
they meet certain origin and destination requirements. A doctors office is not a covered destination.  
 
The services you have asked the Plan to pay for are ambulance transport services to a doctors office. 
Therefore, we decided that the Plan does not have to pay for non-urgent ambulance transport to and from the 
enrollees residence to the physicians office.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluations - problem focused (D0140) 
provided on July 24, 2023, and August 2, 2023. 
 
You asked the Plan to pay for the limited oral evaluations. You say that you were having pain and issues with 
your mouth so you went to see a couple of dentists, but they could not determine what the issue was. You also 
say that the oral evaluations should pay because if the dentists knew what they were doing he would not have 
had to have 3 different evaluations in the first place. The Plan denied your request. The Plan says your benefit 
for the limited oral evaluations 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 services was exhausted on date of service May 15, 2023, and May 23, 
2023. Therefore, we decided that the Plan does not have to pay for the limited oral evaluations - problem 
focused (D0140) provided on July 24, 2023, and August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral  comprehensive series of radiographic 
images (D0210), and periodontal maintenance (D4910) provided on June 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you have had the same dentist for 20 years 
are now expected to change because they are not in-network. 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 the intraoral  comprehensive series of 
radiographic images (D0210), and periodontal maintenance (D4910) provided on June 9, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Retacrit. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found Retacrit is not indicated for the treatment 
of anemia in cancer or cancer treatment patients due to folate deficiency, B-12 deficiency, iron deficiency, 
hemolysis, bleeding, or bone marrow fibrosis. The review has determined that the requested use of Retacrit is 
not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the major drug compendia or 
by clinical research that appears in a CMS-approved medical journal.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you need therapy to gain strength to return to the 
assisted living facility. The Plan denied your request. The Plan says the request for SNF services is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting. You 
do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that you are requesting reconsideration due to 
medical necessity. The Plan denied your request. The Plan says the request for a non-invasive ventilator (NIV) 
is not medically reasonable and necessary. 
 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. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the record indicates that the enrollee 
has chronic respiratory failure from chronic obstructive pulmonary disease. The provided primary source 
documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a BiPAP machine with average volume-assured pressure support 
(AVAPS) capability and failure of such a device has not been documented. The elements of the coverage 
criteria are not satisfied. The requested service cannot be 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 a home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
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 the enrollee would like reconsideration because the 
services are medically necessary. The Plan denied your request. The Plan says an IRF admission is not 
medically necessary.  
 
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 that the complexity of the enrollee's nursing, medical and rehabilitation can be 
provided in a lower level of care and does not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation - established patient 
(D0120), prophylaxis - adult (D1110), and topical application of fluoride  excluding varnish (D1208) 
provided on July 7, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you have been going to this dentist for 40 
years and were surprised to find how little was covered monetarily when you had one cleaning a year. You also 
say that you are asking the amount of coverage be reviewed and increased for the annual visit. 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 the periodic oral evaluation - established 
patient (D0120), prophylaxis - adult (D1110), and topical application of fluoride  excluding varnish (D1208) 
provided on July 7, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81240, 81241). 
 
You asked the Plan to pre-approve genetic testing. You say that you are requesting reconsideration and have 
submitted medical records for review. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for approval of the requested testing. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of genetic testing have not been met. Specifically, the requested genetic testing for FVL, F5 gene, and 
F2 G20210A mutations is indicated for pregnant patients who have a history of personal venous 
thromboembolism (VTE). The records do not show that you are pregnant. Therefore, we decided that the Plan 
does not have to pre-approve genetic testing (81240, 81241).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #25, crowns (D2750) for 
tooth #26 & #23. 
 
You asked the Plan to pre-approve dental services. You say that this dental work is medically necessary.  The 
Plan denied your request. The Plan says the medical criteria has not been met for this dental work. 
 
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 dental 
services 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 dental services. Our physician reviewer 
found the Plan allows for lower anterior bridges in limited cases where there are no missing posterior teeth and 
there are two adjacent missing anterior teeth. In this instance there is a single missing anterior tooth (#25), and two missing posterior teeth in the lower arch (#19 and 30). In addition, the abutment teeth for the proposed 
bridge are inadequate due to severe periodontal disease.   
 
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 dental services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a pontic (D6240) for tooth #25, crowns (D2750) for tooth #26 & #23.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G powered upper extremity range of 
motion assist device, elbow, wrist, hand, finger, single or double upright(s) (L8702). 
 
You asked the Plan to pre-approve a MyoPro Motion G orthosis. You say that there are no in-network 
providers who can supply this device. The Plan denied your request. The Plan says this 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 a MyoPro Motion G orthosis. Our 
reviewer says that the requested MyoPro Motion G orthosis is not considered medically reasonable and 
necessary in this case. Our physician reviewer found the MyoPro Orthosis is not known to be effective, based 
on scientific evidence, professional standards, and expert opinion, in improving health outcomes. The MyoPro is not the standard of care for the enrollee's condition or in widespread use for the enrollee's condition based on 
scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the 
long-term outcomes for the enrollee. There is insufficient evidence in the literature that this device will 
increase participation in bimanual activities. Therefore, the reviewer found that the requested MyoPro Motion 
G orthosis is not medically reasonable or 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 a MyoPro Motion G orthosis have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a MyoPro Motion G powered upper extremity range of motion assist device, 
elbow, wrist, hand, finger, single or double upright(s) (L8702).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erleada. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. 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 pre-approve Erleada.   
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the inhalation of nitrous oxide/analgesia, anxiolysis 
(D9230) provided on June 12, 2023. We also decided that the Plan does not have to waive the copayment for 
the extraction, erupted tooth provided on June 12, 2023. You asked the Plan to pay more for inhalation of nitrous oxide/analgesia, anxiolysis. You also asked the Plan to 
waive the copayment for the extraction, erupted tooth. You say that the $325 charged for a sedation was 
excluded. You also say that the Plan benefits list declares that your copayment for extractions is $25 per tooth 
so you are owed $750.  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.  
 
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 extractions.  
 
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 a $25 copayment for the extraction, erupted tooth. This means 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 extraction, erupted tooth (D7140) provided on June 12, 2023. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the inhalation of nitrous oxide/analgesia, anxiolysis (D9230). 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 the inhalation of nitrous oxide/analgesia, anxiolysis (D9230) provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete denture - maxillary (D5110), and complete 
denture - mandibular (D5120) provided on April 13, 2023. 
 
You asked the Plan to pay for the complete dentures. You say that you feel this does not exceed the frequency 
limitation because you only received one set of dentures. You also say that you were given full credit for your 
original choice of the basic denture which was applied towards the UltimateFit you ended up with. The Plan 
denied your request. The Plan says your benefit for the requested 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 April 22, 2022. Therefore, we decided that the Plan does not have to pay for the complete denture - maxillary (D5110), and 
complete denture - mandibular (D5120) provided on April 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upgraded electronics (E2311, E2313, E2377). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that denial of expandable controller with 
harness and associated electrical connections would not allow the enrollee's equipment to support power tilt, 
recline, elevating legrests and seat elevator. You also say that this would create a barrier for the enrollee to 
access all current efforts made by their healthcare team to provide the enrollee with high quality services. The 
Plan denied your request. The Plan says the notes do not show a medical need to control power options through 
a 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 documentation does not support that the enrollee is unable to control any 
approved power options with their own switches. The enrollee has sufficient upper extremity strength and is 
independent in eating. The documentation does not reveal that the enrollee needs a specialized steering device 
such as a head switch. Therefore, the reviewer found that the requested upgraded electronics are not medically 
reasonable or 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 upgraded electronics (E2311, E2313, E2377).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemotherapy administration (96401) provided on July 
20, 2023. 
 
You asked the Plan to pay for the chemotherapy administration. You say that this should be reprocessed and 
paid. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding 
regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that Prolia should not be billed using a chemotherapy 
administration code.  
 
The case file shows that the drug administered on the date of service in dispute was Prolia (J0897). This drug 
should not be billed using a chemotherapy administration code, but rather with code 96372. Therefore, we 
decided that the Plan does not have to pay for the chemotherapy administration (96401) provided on July 20, 
2023.