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

 
We decided that the Plan does not have to pre-approve Soolantra cream 1% for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this medication has worked well for the enrollee. 
The Plan denied your request. The Plan says that this is not covered 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 Soolantra cream 1% for the 
enrollee.  
 
Benefits for this drug 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the 
enrollee does not have a complex illness that requires daily physician services. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital due to a stroke and acute myocardial 
infarction. The enrollee's course of treatment was complicated by COVID pneumonia. The enrollee is now 
tolerating oral medications and breathing on his own without supplemental oxygen. The enrollee is receiving 
appropriate care at the present acute care hospital. He does not require services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no services available at the 
LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. The requested LTACH services are not medically necessary or 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga tablets. 
 
You asked the Plan to pre-approve Farxiga tablets. You say that this is medically necessary. The Plan denied 
your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug 
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 Farxiga tablets.  
 
Benefits for Farxiga tablets 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 for the comprehensive oral exam (D0150) and panoramic x-rays 
(D0330) provided July 15, 2020, by an out-of-network provider. 
 
You asked the Plan to pay for the dental services. You say that you feel that plan should take care of this bill. 
You cannot afford another bill and had called the plan to make sure and now you have this bill. You do not feel 
this is right. The Plan denied your request. The Plan says enrollee's must receive their dental services from a 
dentist in the dental network. 
 
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 health plan contract 
specifically says that care rendered by a provider that is not part of the supplemental dental network is not 
covered.  
 
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 
comprehensive oral exam (D0150) and panoramic x-rays (D0330) provided July 15, 2020, by an out-of-
network provider.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve fractional ablative laser treatment of burn and traumatic scars for 
functional improvement (CPT Codes: 0479T and 0480T). 
 
You asked the Plan to pre-approve the services. You say that you have a surgery scheduled for February 1, 
2021, because your nostril is closed completely and causing extreme pain. The Plan denied your request. The 
Plan says that this service is considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the documentation supports that the enrollee in this case has significant functional impairment 
as a result of burn contracture. A systematic review of the literature shows that there is abundant existing 
literature regarding the use of ablative fractional lasers in the management of hypertrophic scars which 
demonstrates meaningful qualitative improvement and infrequent minor adverse events. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve fractional ablative laser treatment of burn and traumatic scars for functional improvement (CPT 
Codes: 0479T and 0480T).  
 
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: 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 SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that you are at custodial or maintenance level of care. 
 
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 reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on June 17, 2020. 
 
You asked the Plan to pay for the testing services. You say that the ordering physician determined the medical 
necessity of the services. The Plan denied your request. The Plan says the records do not support the billed 
services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug 
classes. We find that CPT code G0483 is not supported in the medical record. Specifically, drugs, or drug 
classes for which testing is performed, should reflect only those likely to be present, based on the patient's 
medical history, current clinical presentation, and illicit drugs that are in common use. Drugs for which 
specimens are being tested must be indicated by the referring provider. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay 
for the definitive drug testing provided on June 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral out-of-network for hearing aids. 
 
You asked the Plan to pre-approve the referral. You say that the enrollee's hearing aids are broken. The Plan 
denied your request. The Plan says network providers must be used. 
 
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 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 referral out-of-network for hearing aids.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown for tooth #29. 
 
You asked the Plan to pre-approve the crown. You say that this is medically necessary. The Plan denied your 
request. The Plan says crowns are not covered under any condition. 
 
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 
crown for tooth #29.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental  core buildup. 
 
You asked the Plan to pre-approve a core buildup. The Plan denied your request. The Plan says the 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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental  
core buildup.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown on tooth #27 (D6752) and a pontic on tooth #28 (D6240). 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says that these services are not listed as 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. The Plan covers restorative 
dental services. 
 
The requested services are considered restorative dental services. This type of service is explicitly listed as 
covered in the Evidence of Coverage. Based on this information, we decided that the Plan's rules for coverage 
of the services have been met. Therefore, we decided that the Plan has to pre-approve a crown on tooth #27 
(D6752) and a pontic on tooth #28 (D6240).  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis (22558), anterior instrumentation (22845), 
and the insertion of an interbody biomechanical device (22853). 
 
You asked the Plan to pre-approve arthrodesis, anterior instrumentation, and the insertion of an interbody 
biomechanical device. You say that this is necessary because the enrollee is in pain. 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 arthrodesis, anterior instrumentation, 
and the insertion of an interbody biomechanical device. Our reviewer says that the requested services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found clinical guidelines 
indicate that lumbar fusion is appropriate if there has been adequate conservative management including 
physical therapy, complementary conservative management including chiropractic or acupuncture, failure of 
anti-inflammatory medication and analgesics along with documented instability.  In this case, there is no 
documentation of instability or spondylolisthesis in the lumbar spine.  There was no evidence of any significant 
spinal or neural foraminal narrowing and no documentation of the results of the flexion/extension lumbar 
radiographs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis, anterior instrumentation, and the insertion of an interbody 
biomechanical device have not been met. Therefore, we decided that the Plan does not have to pre-approve 
arthrodesis (22558), anterior instrumentation (22845), and the insertion of an interbody biomechanical device 
(22853).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient diagnostic services with CPT code 77062 
provided on August 18, 2020. 
 
You asked the Plan to pay for CPT code 77062. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 looked at the file and Medicare rules. In this case, CPT code 77062 has a status code of "I" under the 
Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses 
another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have 
to pay for the outpatient diagnostic services with CPT code 77062 provided on August 18, 2020.
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 does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for lumbar decompression surgery which was complicated by ileus, wound dehiscence, colitis and 
pulmonary embolism. Medical conditions are stable. There are no medical needs requiring inpatient admission. 
There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the medical record documents a need for physical and occupational therapy, it does not 
document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient 
will be able to fully participate in and benefit from the 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Computed Tomography (CT) scan of the chest. 
 
You asked the Plan to pre-approve CT scan. You say that the enrollee has been an avid smoker for many years 
and needs to have this done. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because this test is not covered for screening purposes and other testing methods would be 
more appropriate. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, CT scan, is being requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve 
a Computed Tomography (CT) scan of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered from April 15, 2019 to May 5, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for these services was not filed until September 2, 2020. A valid waiver of 
liability (WOL) was not received until October 12, 2020. This means that more than one calendar year from the 
date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay 
for the services rendered from April 15, 2019 to May 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and core buildup 
(D2950) provided on September 15, 2020. 
 
You asked the Plan to pay for the porcelain/ceramic crown and core buildup. You say that you would like this 
claim processed at a previous amount the Plan provided. The Plan denied your request. The Plan says these 
services are not covered under the supplemental 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 pay for the 
porcelain/ceramic crown (D2740) and core buildup (D2950) provided on September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on August 13, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 outpatient services provided on August 13, 
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 acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need therapies you will not get at a skilled 
nursing facility. The Plan denied your request. The Plan says it is not reasonable to expect that you will be able 
to participate or benefit from the intensity of services in an IRF. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for a hip fracture after a fall. You are at a minimal assist level for 
sitting up, contact guard assist for standing up, and at minimal assist for walking using a four-wheeled walker. 
You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require 
fifteen hours per week of rehabilitative services and regular physician evaluation. 
 
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.