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

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture 
(D5120). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The 
Plan says you were provided a complete maxillary (D5110) and a complete mandibular denture (D5120) on 
June 6, 2019, which is less than five years ago. 
 
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, the requested complete maxillary 
denture (D5110) and complete mandibular denture (D5120) are not covered at this time as the file shows you 
received these services on June 6, 2019, which is less than five years ago. Therefore, we decided that the Plan 
does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture 
(D5120).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your 
request. The Plan says step therapy criteria have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that the 
criteria for coverage of Euflexxa have not been met. Our physician reviewer found the enrollee has not trialed 
viscosupplemental treatments such as Orthovisc and Monovisc.  Step therapy, as outlined by the plan, requires 
these be trialed first. The documentation does not outline contraindications or reasons these medications were 
not considered. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Auryxia. 
 
You asked the Plan to pre-approve Auryxia. You say that the enrollee cannot tolerate other phosphate binders. 
The Plan denied your request. The Plan says this medication does not fall under Part B. 
 
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 Auryxia.  
 
Benefits for Auryxia 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for physician services provided by a non-
participating provider on May 27, 2020. 
 
You asked the Plan to waive the deductible for physician services. You say that you called and was told they 
took your insurance. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $1,500 deductible for physician/practitioner services/out-of-network.  
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category 
physician/practitioner services/out-of-network. The Plan has followed Medicare rules by clearly disclosing in 
the contract that there is $1,500 deductible for physician/practitioner services/out-of-network. This cost sharing 
is a contractual obligation that had not been met at the time physician services was received on May 27, 2020. 
The total amount you are being asked to pay is $181.43. Therefore, we decided that the Plan does not have to 
waive the deductible for physician services provided by a non-participating provider on May 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on September 26, 
2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria were not met.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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 this service. Our reviewer says that Medicare coverage criteria are not met. Our physician 
reviewer found the medical records provided do not support the services billed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for physician services provided to the enrollee on September 26, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the laboratory services provided on  
May 29, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 
copayment for laboratory services provided at an outpatient hospital.  
 
You have been asked to pay a $10 copayment for the laboratory services provided at an outpatient hospital. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the copayment for the laboratory services provided on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services (code 12052), provided to the enrollee on 
November 12, 2019. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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 this service. Our reviewer says that Medicare coverage criteria are not met. Our physician 
reviewer found the enrollee was billed for Common Procedural Terminology (CPT) 12052 described as  
?Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm.?  
However, the procedure report does not document the level of service billed.  Medicare billing criteria are not 
met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided 
that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for physician services (code 12052), provided to the enrollee on November 12, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the routine venipuncture (36415), comprehensive metabolic 
panel (80053), 25 hydroxy includes fractions is performed (82306) and lipid panel (80061) provided on March 
2, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for routine venipuncture, comprehensive metabolic panel, 25 hydroxy includes 
fractions is performed and lipid panel. You say that the services rendered were medically necessary. The Plan 
denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by 
an out-of-network provider. 
 
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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the routine venipuncture (36415), comprehensive 
metabolic panel (80053), 25 hydroxy includes fractions is performed (82306) and lipid panel (80061) provided 
on March 2, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99213) provided on May 19, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for an OON office visit. You say that you did not have a referral because you are out 
of network. The Plan denied your request. The Plan says out of network services require 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 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. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit (99213) provided on May 19, 2020 
by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from 
October 16, 2020 and forward. 
 
You asked the Plan to pre-approve continuation of inpatient mental health care from October 16, 2020 and 
forward. You say that the requested continuation of inpatient mental health care from October 16, 2020 and 
forward is medically necessary. The Plan denied your request. The Plan says the requested continuation of 
inpatient mental health care from October 16, 2020 and forward is 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 continuation of inpatient mental health 
care from October 16, 2020 and forward. Our reviewer says that the requested continuation of inpatient mental 
health care from October 16, 2020 and forward is not medically necessary. Our physician reviewer found this 
enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a 
danger to herself or others and did not have any auditory or visual hallucinations while being cooperative with 
treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear 
that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. This enrollee was treated under an individualized treatment plan found in the 
record. It did appear that the records were supervised and evaluated by a physician. Based upon review of the 
records provided this enrollee does not meet the criteria for continued acute inpatient mental health treatment 
for the dates in question of October 16, 2020 forward as this enrollee was not shown to be a danger to herself or 
others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with 
treatment while not showing any threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of inpatient mental health care from October 16, 2020 and forward 
have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient 
mental health care from October 16, 2020 and forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyzulta Sol 0.024% for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the prior authorization request indicates that this is to be self-administered. 
 
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 Vyzulta Sol 0.024% for the 
enrollee.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that IRF admission is necessary. The Plan denied your 
request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 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 based on review of the medical records, 
the enrollee does not meet the CMS coverage criteria for an IRF admission. She is generally medically after 
sustaining right UE fractures and surgery with no evidence of medical or nursing needs for an IRF and her 
current functional status does not require IRF level of therapies. There is no evidence of medical issues that 
require monitoring by an inpatient rehab physician three times a week. The documentation does not support 
that there is a need for an intensive therapy program with 3 hours a day and an interdisciplinary approach to 
rehab care. IRF admission is not medically necessary for this enrollee, and also does not meet the CMS 
coverage criteria. Her rehab needs can be safely and effectively met in an alternate, less intense setting such as 
in-home with services. 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a therapeutic continuous glucose monitor (CGM). You say that you would 
like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet 
Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they 
are medically reasonable and necessary and replace a blood glucose monitor.  
 
We looked at the file and Medicare rules. Medicare rules also say that therapeutic CGMs are covered only 
when a patient has been performing four or more blood glucose testing?s every day and is insulin-treated with 
at least three or more daily injections of insulin or a Medicare-covered continuous subcutaneous insulin 
infusion (CSII) pump. The file shows that you are neither insulin-treated nor have a CSII pump. Therefore, we 
decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the patient's functional status requires or can tolerate an intensive rehabilitation therapy program 
provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vyepti. 
 
You asked the Plan to pre-approve Vyepti. You say that you would like the plan to reconsider their denial. The 
Plan denied your request. The Plan says the requested drug does not meet criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Vyepti. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has chronic migraine headaches. She has failed treatment with Emgality, Imitrex, 
Maxalt, Fioricet, Migranal and Nurtec among others. The documentation does not support that the enrollee has 
tried and failed Effexor (venlafaxine), Topamax (topiramate) and Aimovig (erenumab). The documentation 
does not support that the plan's required drugs would likely be less effective and/or likely have adverse effects 
for the enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vyepti have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Vyepti.
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. The Plan denied your request. The Plan says 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 above. 
 
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 enrollee does not require the intensity of services provided at an IRF. 
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the 
enrollee's needs are considered custodial. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
Continued services beyond October 11, 2020 were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, the 
enrollee received oral medications, dialysis, and had stable vital signs. There are no identifiable skilled nursing 
service needs. Regarding rehab services, the enrollee is at a minimal to maximal assist for functional mobility. 
She required varying assist with activities of daily living. There are no identifiable skilled therapy service 
needs. She does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet 
severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 continued services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve continued skilled nursing facility (SNF) services.