Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan 
denied your request. The Plan says that ongoing skilled services can be provided at a lower level of care. 
 
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. 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 when your activity level is impaired. Your rehab needs can be 
met in an alternate, less intense setting. Our physician reviewer found that your condition does not meet 
Medicare criteria for IRF 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that the ventilator is medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that home ventilators are 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 the ventilator. Our reviewer says that 
the ventilator is not medically necessary. Our physician reviewer found Medicare does not cover a portable 
ventilator when used as BiPAP. Certain BiPAP devices are capable of providing the AVAPS mode of support, 
if needed. BiPAP at night is the appropriate treatment for this patient.  A portable ventilator is not medically 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interspinous process stabilization device surgery. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested device is contraindicated per FDA guidelines. 
 
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 device. Our reviewer says that the 
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the spacer is experimental. More research is needed to show safety and efficacy. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the interspinous process stabilization device surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous glucose monitor supplies (A9276, A9277, 
A9278) for the enrollee. 
 
You asked the Plan to pre-approve the supplies. You say that the enrollee has severe hyperglycemia with a 
need for paramedics to be called. The Plan denied your request. The Plan says the "A Codes" that were 
requested are never covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that HCPCS A9276, A9277, and A9278 are not 
covered.  
 
The requested services are billed with codes that are statutorily not covered. Based on this information, we 
decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continuous glucose monitor supplies (A9276, A9277, A9278) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the lab services you received on July 8, 
2020. 
 
You asked the Plan to waive the deductible. The Plan denied your request. The Plan says your deductible was 
not met. 
 
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 a $250 deductible you must pay out-of-pocket before the Plan will pay 
its share for covered medical services.  
 
Review of the file shows that you were provided lab services on July 8, 2020. The Plan has followed Medicare 
rules by clearly disclosing in the contract that there is a $250 deductible you must meet before lab tests are 
covered with a $0 copayment. This cost sharing is a contractual obligation that had not been met at the time the 
lab services was received on July 8, 2020. Therefore, we decided that the Plan does not have to waive the 
deductible for the lab services you received on July 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a 
participating provider on June 24, 2020 to June 29, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you already paid this 
copayment earlier this year. The Plan denied your request. The Plan says you had not met your maximum out-
of-pocket expense about at the time of these services. 
 
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 $325 
copayment per day for days 1-4. There is a $0 copayment for additional days for inpatient mental health care.  
 
You have been asked to pay a $325 copayment per day for days 1-4. There is a $0 copayment for additional 
days for an inpatient hospital stay. The total amount you are being asked to pay is $1,300 ($325 x 4 days = 
$1,300). An inpatient hospital stay falls within the inpatient mental health care 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 an inpatient hospital stay provided by a participating provider on 
June 24, 2020 to June 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for insulin provided by a participating 
provider on March 19, 2020. 
 
You asked the Plan to waive the coinsurance for insulin. You say that you've never had to pay for this before. 
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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for insulin. The total allowed amount is 
$3,054.60. The total amount you are being asked to pay is $610.92 ($3,054.60 x 20% = $610.92). Insulin falls 
within the Medicare Part B prescription drugs 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 coinsurance 
for insulin provided by a participating provider on March 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable and suitable for 
transfer to an LTACH. You say that she cannot be adequately cared for at a skilled nursing facility. The Plan 
denied your request. The Plan says it is not medically necessary to be in an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where she is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration, bone replacement graft and 
nitrous oxide/analgesia provided on July 13, 2020. 
 
You asked the Plan to pay for the guided tissue regeneration, bone replacement graft and nitrous 
oxide/analgesia. You say that you were given a cost estimate of $90. You say that the dental office called to 
verify benefits. The Plan denied your request. The Plan says the 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 pay for the 
guided tissue regeneration, bone replacement graft and nitrous oxide/analgesia provided on July 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections (64450) and betamethasone (J0702) provided on 
November 28, 2018. 
 
You asked the Plan to pay for injections and betamethasone. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the billed units are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 3 units of CPT code 64450 and 12 units of J0702 are not supported in the medical record. The 
medical record only supports 1 unit of CPT code 64450 and 4 of J0702. Based on this information, we decided 
that Medicare rules for coverage of injections and betamethasone have not been met. Therefore, we decided 
that the Plan does not have to pay for injections (64450) and betamethasone (J0702) provided on November 28, 
2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durvalumab 10mg 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 there is no evidence of stage III lung cancer. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has stage 
IV disease. This drug is approval for stage III cancer. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve durvalumab 10mg for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an EKG provided on January 27, 2020. 
 
You asked the Plan to waive the copayment for an EKG. You say that 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 $10 
copayment for diagnostic procedures and tests.  
 
You have been asked to pay a $10 copayment for an EKG. An EKG falls within the outpatient diagnostic tests 
and therapeutic services and supplies 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 
an EKG provided on January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown on tooth 18 and 20, and pontic for 
tooth 19 for the enrollee. 
 
You asked the Plan to pre-approve these dental services. You say that these dental services are medically 
necessary. The Plan denied your request. The Plan says the requested dental services are not shown to be 
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 these dental 
services. Our reviewer says that the requested services are not considered medically reasonable and necessary 
in this case. Our physician reviewer found based on the dental records provided, replacement of a posterior 
tooth with a fixed bridge does not meet the criteria for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these dental services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a retainer crown on tooth 18 and 20, and pontic for tooth 19 for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis. 
 
You asked the Plan to pre-approve Renflexis. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says Medicare coverage criteria are not 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 Renflexis. Our 
reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the documentation 
does not support that Remicade, Inflectra, and Simponi Aria (two of the three) would likely be less effective, 
and/or would likely have adverse effects in this case. We looked at this physician's review, the file, and 
Medicare rules. Based on this information, we decided that Medicare rules for coverage of Renflexis have not 
been met. Therefore, we decided that the Plan does not have to pre-approve Renflexis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on March 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation and confirm that 
Medicare coverage criteria have been met.  
 
We looked at the file and Medicare rules. The documentation submitted does not contain records for the date of 
services in question. Without records, it cannot be confirmed that Medicare coverage criteria have been met. 
Therefore, we decided that the Plan does not have to pay for the services provided on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve out of network services. You say that it is necessary for the enrollee to see 
this provider. The Plan denied your request. The Plan says this service can be provided in network. 
 
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 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 the 
medical services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve peripheral nerve blocks. 
 
You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is considered experimental. 
 
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 blocks. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found this is considered an experimental/investigational procedure. Therefore, the request is considered 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 blocks have not been met. Therefore, we decided that the Plan does not have 
to pre-approve peripheral nerve blocks.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Praluent 75mg/ml pen. 
 
You asked the Plan to pre-approve Praluent. You say that Praluent is medically necessary. The Plan denied 
your request. The Plan says this medication is not eligible for coverage under the Part B medical benefit. 
 
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 a Praluent 75mg/ml pen.  
 
Benefits for Praluent 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis, the shoulder-elbow-wrist-hand 
orthosis, the knee orthosis and suspension sleeve provided on February 22, 2020. 
 
You asked the Plan to pay for the lumbar-sacral orthosis (L0650), the shoulder-elbow-wrist-hand orthosis 
(L3960), the knee orthosis (L1851)and suspension sleeve (L2397). You say that the orthoses were medically 
necessary. The Plan denied your request. The Plan says criteria for telehealth services have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
 
 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis, 
the shoulder-elbow-wrist-hand orthosis, the knee orthosis and suspension sleeve provided on February 22, 
2020.