Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar facet joint blocks. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not had pain for at least 3 months. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint blocks are only covered under certain 
medical indications.  
 
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 requested services. Our physician 
reviewer found that the enrollee has a history of low back pain with intermittent radiation to the posterior thigh 
over the past month. The pain is rated as a 6 out of 10 in severity, and described as sharp in nature. The records 
do not show that the enrollee has had chronic pain for 3 months. Therefore, the requested facet injections are 
not medically reasonable or necessary to treat the enrollee. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve lumbar facet joint blocks.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee is 
currently medically stable, and daily therapies are not necessary. 
 
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. 
 
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 services. Our physician reviewer 
found that the enrollee is at an independent assist level with bed mobility, sitting up, and lying down. He is at a 
contact guard assist level for standing up, and ambulation using a wheeled walker. The enrollee does not have 
documented skilled nursing needs or skilled therapy needs. He is consistently ambulating more than 100 feet 
and tending to activities of daily living with minimal supervision. Daily skilled services are not required to 
establish a maintenance program or to prevent deterioration of your condition. The enrollee's care needs at this 
point are custodial. 
 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the low dose computed tomography scan (LDCT) 
(G0297). 
 
You asked the Plan to pre-approve the low dose CT scan. You say that you hope that the plan will agree with 
your recommendation and approve this medically necessary treatment. The Plan denied your request. The Plan 
says the enrollee does not meet generally accepted criteria for CT imaging to screen for lung cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the low dose CT scan. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
 physician reviewer found review of the submitted documentation does not support a 30 pack-year history of 
tobacco smoking history. Without the support of the documentation, medical necessity cannot be determined. 
 
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 low dose CT scan have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the low dose computed tomography scan (LDCT) (G0297).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the plan.  
 
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 requested provider in this case is not a network provider with the Plan. The Plan has 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 the 
requested physician's services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fourteen (14) hours of home health aide services 
(G0156). 
 
You asked the Plan to pre-approve home health aide services. You say that the services are necessary in order 
for you to effectively meet the patient?s personal care needs. The Plan denied your request. The Plan says the 
services requested are not supporting a skilled need and are custodial care that does not require the continuing 
attention of trained medical or paramedical personnel. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health aide have not been met. Specifically, the enrollee is not receiving a qualifying skilled 
service in this case. Therefore, we decided that the Plan does not have to pre-approve fourteen (14) hours of 
home health aide services (G0156).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a hospital bed (E0260). 
 
You asked the Plan to pre-approve a hospital bed. You say that the bed is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that a hospital bed is covered when medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a hospital bed. Our reviewer says that 
the hospital bed is not medically necessary. Our physician reviewer found the provided documentation does not 
contain a mobility assessment, an in-bed mobility assessment, any evidence that the enrollee cannot position 
himself in a regular bed or any evidence that the enrollee requires immediate and frequent repositioning when 
in bed. As such, the documentation does not support that a hospital bed, fixed-height or electric, is medically 
necessary and reasonable.  

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 hospital bed have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a hospital bed (E0260).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter (E1230). 
 
You asked the Plan to pre-approve the power scooter. You say that the power scooter is medically necessary. 
The Plan denied your request. The Plan says the power scooter is for use outside the home and is not covered. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The record shows the item at issue in this appeal is for use outside of the home. Although this item may be 
helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that 
the Plan does not have to pre-approve a power scooter (E1230).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that your current 
denture is defective. The Plan denied your request. The Plan says these services exceed the maximum count 
allowed per period. 
 
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, maxillary partial denture (D5213) and 
mandibular partial denture (D5214) are each limited to one procedure every five plan years. The record shows 
that you received maxillary and mandibular partial dentures on June 29, 2018, and your maxillary denture and 
mandibular denture benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-
approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).  
 
Your complaint about the issues you had with the customer service representatives is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that this would benefit the enrollee. The 
Plan denied your request. The Plan says the enrollee does not meet criteria for coverage. 
 
 
 
The Plan must follow Medicare rules. Medicare rules say that CGMs and related supplies are covered when the 
beneficiary is insulin-treated with multiple (three or more) daily injections of insulin or a Medicare-covered 
continuous subcutaneous insulin infusion (CSII) pump. 
 
We looked at the file and Medicare rules. The record shows that the enrollee is not insulin-treated. Based on 
this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor 
(CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete mandibular overdenture (D5865). 
 
You asked the Plan to pre-approve the complete mandibular overdenture. You say that you are unable to eat or 
digest food because you do not have lower teeth to chew your food properly. The Plan denied your request. The 
Plan says this service is not covered. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
complete mandibular overdenture (D5865).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a periodontal scaling and root planing and fixed 
prosthodontic procedure. 
 
You asked the Plan to pre-approve the periodontal scaling and root planing and fixed prosthodontic procedure. 
You say that the dentist needs to do a deep cleaning under the bridge first because of an infection. The Plan 
denied your request. The Plan says these services are not covered benefits. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
periodontal scaling and root planing and fixed prosthodontic procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pontics (D6542) for teeth # 5, 7, 8, 9, 11, and 12, 
retainer crowns (D6740) for teeth # 4, 6, 10, and 13, a bone replacement graft for ridge preservation (D7953) 
for tooth # 11. 
 
You asked the Plan to pre-approve the bridge and bone replacement graft. You say that the enrollee's current 
bridge is very loose. You say that the enrollee had this bridge done 4 years ago at another office. The Plan 
denied your request. The Plan says the documentation provided fails to indicate any specific needs or 
conditions that preclude use of a removable prosthesis. The Plan also says that bone replacement graft for ridge 
preservation is not listed as 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 Plan's coverage rules apply in this case. The Plan covers the bridge and 
bone replacement graft 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 the bridge and bone replacement graft. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the provided 
documentation indicates that the current bridge (placed 4 years ago) is loose and teeth # 5 and 12 need to be 
replaced. The reviewer found that teeth # 5 and 12 would not increase the enrollee's occlusal function to any 
degree. Therefore the reviewer found that the requested bridge is not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the bridge and bone replacement graft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve pontics (D6542) for teeth # 5, 7, 8, 9, 11, and 12, retainer 
crowns (D6740) for teeth # 4, 6, 10, and 13, a bone replacement graft for ridge preservation (D7953) for tooth #11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two retainer crowns (D6750 x2) and two pontics 
(D6240 x2). 
 
You asked the Plan to pre-approve the bridge. You say that at the time of enrollment, you were told that the 
Plan's supplemental dental plan covered bridges. The Plan denied your request. The Plan says this service is not 
a covered benefit. 
 
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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
retainer crowns (D6750 x2) and two pontics (D6240 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 10, 2020. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that this was a follow-up visit and 
you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly 
and you are being charged the correct amount. 
 
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 $40 
copayment for specialist visits. 
 
You had a follow-up visit on June 10, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, 
you are responsible to pay the $40 copayment.  
 
You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the 
physician/practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for a specialist visit provided on June 10, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Jevtana. 
 
You asked the Plan to pre-approve Jevtana. You say that the enrollee is doing well on this drug. The Plan 
denied your request. The Plan says that the use of this drug is not medically indicated. 
 
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 Jevtana. Our reviewer says that the 
requested Jevtana is medically reasonable and necessary in this case. Our physician reviewer found the patient 
had a positive response to Jevtana but was on a chemotherapy holiday and now has progression. He did not 
progress on Jevtana. Jevtana is FDA approved for this use. The enrollee received docetaxel in the past and had 
progression. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Jevtana have been met. Therefore, we decided that the Plan has to pre-approve 
Jevtana.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 22, 
2020. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you were not aware of the 
charges and cannot afford them. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 $215 
copayment for ambulance services.  
 
You have been asked to pay a $215 copayment for ambulance services. Ambulance services fall within the 
ambulance services benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services 
provided on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the insertion of a heart rhythm monitor 
under skin provided from May 15, 2020, to May 22, 2020. 
 
You asked the Plan to waive the copayment for the insertion of a heart rhythm monitor under skin. You say that 
you understand that the copayment is waived for outpatient services. The Plan denied your request. The Plan 
says the claims were processed correctly and you are being charged the correct amount. 
 
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 $200 
copayment for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay a $200 copayment for the insertion of a heart rhythm monitor under skin. The 
insertion of a heart rhythm monitor under skin falls within the outpatient surgery, including services provided 
at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the insertion of a heart rhythm monitor under skin provided from May 15, 2020, to 
May 22, 2020.
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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve elevating leg rests for a power wheelchair (PWC). 
 
You asked the Plan to pre-approve these services. You say that you have had your power wheelchair since 
2001 and it is falling apart. The Plan denied your request. The Plan says that the services are not medically 
necessary. 
 
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. The Plan states that the elevating leg rests are not medically necessary but there 
are no medical records with the submitted case file. Without medical records, a determination based on medical 
records cannot be supported. Therefore, we decided that the Plan has to pre-approve elevating leg rests for a 
power wheelchair (PWC).