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

 
We decided that the Plan does not have to pre-approve additional non-emergent transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that you need to see your PCP, endocrinologist, 
and cardiologist. The Plan denied your request. The Plan says the 25th trip and beyond is not a covered benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. You have used 20 of the 24 trips for 2020. 
Once you hit 24 trips, the benefit will be exhausted. Additional trips cannot be requested. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergent transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627). 
 
You asked the Plan to pre-approve a seat lift mechanism. You say that this would benefit the enrollee. The Plan 
denied your request. The Plan says the enrollee does not have a condition for which this is covered. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if the enrollee has 
severe arthritis of the hip or knee or have a severe neuromuscular disease. 
 
We looked at the file and Medicare rules. The records show that the enrollee does not have severe arthritis of 
the hip or knee or have a severe neuromuscular disease. Based on this information, we decided that Medicare 
rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a seat lift mechanism (E0627).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prism lenses. 
 
You asked the Plan to pre-approve prism lenses. You say that because of your medical condition you need 
prism lenses. The Plan denied your request. The Plan says specialty lenses are not covered under your Vision 
benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover enhanced upgrades to standard eyewear. 
 
The services you asked the Plan to pre-approve is considered enhanced eyewear. Therefore, we decided that the 
Plan does not have to pre-approve prism lenses.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve scar revision surgery. 
 
You asked the Plan to pre-approve scar revision surgery. You say that you have 2 scars on your face near your 
eye that you would like to get covered up by plastic surgery. You do not like how noticeable they are. Ever 
since the injury your eye sight has not been the same. The Plan denied your request. The Plan says the surgery 
is cosmetic in nature and is not a covered benefit. 
 
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 scar revision surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the documentation provided for this review, the enrollee has an immature 
scar of the glabella region from a fall.  Recommendation has been made for conservative management to allow 
the scar to fully mature.  Thus, it would be premature to perform any scar revision.  In addition, the enrollee is 
being treated for a possible optic injury with steroids, which could complicate any procedure that requires 
healing. As the medical documentation does not support that scar revision is indicated at this time, it does not 
satisfy Medicare medically necessary criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of scar revision surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve scar revision surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper partial denture-metal framework (D5213). 
 
You asked the Plan to pre-approve the upper partial denture-metal framework (D5213). You say that the 
enrollee is missing tooth #2, 4, and 14. You say that they need an upper partial. The Plan denied your request. 
The Plan says the service is allowed once every 5 years. 
 
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 Plan also have a maximum benefit 
of one of D5110, D5130, D5211, D5213 per 60 months. The Plan paid for an upper partial denture-resin based 
(D5211) on November 15, 2017, which exhausted the benefit. Therefore, we decided that the Plan does not 
have to pre-approve the upper partial denture-metal framework (D5213).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve Xarelto. The Plan denied your request. The Plan says this is not covered 
under your Part B 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 Xarelto.
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 IRF care is medically necessary as the enrollee needs 
multiple therapies. The Plan denied your request. The Plan says the request for admission to an inpatient 
rehabilitation facility is considered 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 while the enrollee may benefit from continuing therapy, there is no evidence of need 
for an intensive therapy program, frequent physician oversight or an interdisciplinary approach to rehabilitation 
care. Our reviewer says that rehabilitation needs can be met in a lower intensity alternate 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 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 Vytone 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 Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Vytone for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Testosterone 1.62% (1.25g) 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 Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Testosterone 1.62% (1.25g) 
for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia 60mg syringe. 
 
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your 
request. The Plan says a trial of both oral and intravenous bisphosphonates is required before alternatives can 
be approved. 
 
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 Prolia. Our reviewer says that the Prolia 
injections are not medically necessary. Our physician reviewer found the record does not show a trial of the 
plan preferred drugs or any reason they would be unsafe or ineffective for 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia 60mg syringe.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia (J0897). You say that you want the enrollee treated with this drug. 
The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or 
intolerance to bisphosphonate, and there was no bone density test result showing that the enrollee did not 
improve while taking alendronate for an adequate amount of time. 
 
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 Prolia (J0897). Our reviewer says that 
the drug is not medically necessary. Our physician reviewer found based on the medical records provided there 
is no documentation that Prolia is medically reasonable and necessary for the enrollee. The records do indicate 
a worsening of the enrollee's hip bone density over time but it is not clear as to when, how long (or how 
consistently) the enrollee took alendronate. Based on the medical records provided there is no documentation 
that Prolia is safe and effective for 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 Prolia (J0897) have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897) 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  
 
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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found there is no history of 
osteoporotic fracture. The Plan requires a trial of Zoledronic Acid before they will approve the requested drug. 
In this case, the enrollee has not tried and failed the required drug. There is no documentation provided 
indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia (J0897) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sureclick 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 Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 Repatha Sureclick for the 
enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on October 1, 2019. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior 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 did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on October 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the 
out of network (OON) provider on November 6, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99335) rendered by the out of network (OON) provider on 
November 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for IRF services provided from November 4, 2019 to November 
14, 2019. 
 
You asked the Plan to pay for the IRF services. The Plan denied your request. The Plan says that the enrollee 
generally must receive your care from a network provider. In most cases, care the enrollee receives from a non-
network provider will not be covered. 
 
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 did not pre-approve the 
IRF services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for IRF services provided from November 4, 2019 to November 14, 
2019.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says the services are 
available 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 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 medical 
services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on March 17, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan 
requires utilization of network providers when possible and available, and requires authorization for certain 
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has 
been documented.   
 
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 did not pre-approve the 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the 
out of network (OON) provider on December 18, 2019. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior 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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the domiciliary or rest home visit (99336) rendered by the out of network (OON) provider on 
December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy services provided on December 2, 2019. 
 
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy services provided on December 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiologic examination, chest 1 view (71045-26) computed 
tomography, head or brain, without contract material (70450-26) provided March 10,2020 to March 15, 2020. 
 
You asked the Plan to pay for the radiology services. You say that the records attached supports that this 
procedure was performed by your provider. The claim denied as duplicate in error. Please review and reprocess 
claim for reimbursement according to contract. The Plan denied your request. The Plan says this is a duplicate 
of a charge considered on a previous claim. In order to show that there were 2 separate interpretations 
completed at different sessions you would need to see documentation for both. 
 
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, based on the documentation provided, the files shows that these services were already paid to the 
same provider for the same dates of service. Based on this information, we decided that Medicare rules for 
coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay 
for radiologic examination, chest 1 view (71045-26) computed tomography, head or brain, without contract 
material (70450-26) provided March 10,2020 to March 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided December 9, 2019 to 
December 10, 2019. 
 
You asked the Plan to pay for the inpatient hospital services. You say that this claim was denied to got to your 
other insurance carrier but you only have this plan. The hospital told you that the plan has to reprocess the 
claim or it will come back as a duplicate claim. The Plan denied your request. The Plan says the provider 
submitted these services as a verification of non-covered 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, a correct claim is needed before the Plan can reprocess the claim. The plan has made multiple 
attempts to obtain the necessary information from the provider. Based on this information, we decided that 
Medicare rules for coverage of the inpatient hospital services have not been met. Therefore, we decided that the 
Plan does not have to pay for the inpatient hospital services provided December 9, 2019 to December 10, 2019.