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

We decided that the Plan does not have to pre-approve Glyburide tablet for the enrollee.

You asked the Plan to pre-approve the drug. You say that the enrollee cannot be switched to Glypizide due to a sulfa drug allergy. 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 Glyburide tablet for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CPAP device provided on May 3, 2020. 
 
You asked the Plan to pay for the CPAP device. 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 
CPAP device. We found no exception that would require the Plan to pay for this item. Therefore, we decided 
that the Plan does not have to pay for a CPAP device provided on May 3, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 20, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the billed services 
cannot be verified. 
 
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 find that CPT codes at issue in this case, 80157, 80177, 80201, 80159, and 80173, are not supported in the 
medical record. The material used for testing of these services is whole blood, serum, plasma, or cerebrospinal 
fluid. The documentation provided does not indicate a blood sample was provided for the testing services. 
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 lab services provided on November 20, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on June 24, 2020. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 find that the Guardant360 testing is not supported in the medical record. Specifically, this service should be 
billed with code 81479. In addition, the appropriate DEX Z Code identifier should be entered adjacent to the 
code in the comment/narrative field. Based on this information, we decided that Medicare rules for coverage of 
the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the 
Guardant360 testing provided on June 24, 2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the member does not require skilled nursing 
and/or skilled therapy services on a daily basis.  The member is medically stable and can receive further rehab 
services at a lower level of care. Although further rehab services would be appropriate to improve function, as 
a practical matter, the daily skilled services can be provided at a lower level of care than a skilled nursing 
facility. The member does not have any parental medication; complex wound care or nutrition given via a 
feeding tube. The member is medically stable without any acute exacerbations of chronic medical problems. 
The member's physical function is at or near their baseline and the member can receive services at a lower level 
of care. Admission to a SNF for inpatient skilled rehab services 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Granix (J1447). 
 
You asked the Plan to pre-approve Granix. You say that the medication is necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has 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 Granix. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the documentation does not support that 
Zarxio and Nivestym would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Granix have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Granix (J1447).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a spinal cord stimulator. 
 
You asked the Plan to pre-approve the requested services. You say that you can barely walk. The Plan denied 
your request. The Plan says you have not tried and failed conservative therapy. 
 
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is 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 you have had low back pain since your laminectomy for spinal stenosis. You have not had 
trials of conservative therapy such as physical therapy, massage, chiropractic or physical medicine modalities. 
You have not had epidural steroid injections or other nerve blocks. You also have not had a psychological 
evaluation. Therefore, you do not meet the coverage criteria, and the requested service is considered not 
medically reasonable or necessary at this time. 
 
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 a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on April 13, 2020. 
 
You asked the Plan to pay for the physician's 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 
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 April 13, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion services (S9328) provided April 8, 2020 to 
July 29, 2020. 
 
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the CPT code billed is 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 find that CPT code S9328 is not supported in the medical record. Specifically, CPT code S9328 is listed 
with a status "I" indicator and is not valid for Medicare payment. Based on this information, we decided that 
Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the 
Plan does not have to pay for home infusion services (S9328) provided April 8, 2020 to July 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for postoperative, prefabricated, hip orthosis (L1686), and 
Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each 
(L1686). 
 
You asked the Plan to pay for the orthosis. You say that you have attached all the supporting documentation. 
Please reprocess the claim. The Plan denied your request. The Plan says this request is not medically necessary 
because the records do not show an appropriate face-to-face encounter documented to substantiate the need for 
this item. 
 
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 pay for the orthosis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there are no medical records provided indicating a patient encounter with a physician that 
would lead to a decision for right hip orthotic to be prescribed. There is no examination notated and/or 
diagnosis. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for postoperative, prefabricated, hip orthosis (L1686), and Addition to lower extremity, pelvic 
control, hip joint, adjustable flexion, extension, abduction control, each (L1686).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic ultrasound provided by a 
participating provider on January 21, 2020. 
 
You asked the Plan to waive the copayment for a diagnostic ultrasound. You say that you can't be charged 
more than $20 for this. The Plan denied your request. The Plan says the correct copayment 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 $125 
copayment for outpatient diagnostic tests/radiological diagnostic services.  
 
You have been asked to pay a $125 copayment for a diagnostic ultrasound. A diagnostic ultrasound falls within 
the outpatient diagnostic tests/radiological diagnostic 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 a diagnostic ultrasound provided by a participating provider on January 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires long term ventilator 
wearing and has complex medical issues that cannot be handled at a lower level of care. The Plan denied your 
request. The Plan says that the enrollee's medical needs are being met in the current acute setting. 
 
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. The patient 
appears to be improving but requires additional acute care services to ensure stability and to find out which 
level of care would be appropriate, which can safely be completed at the current facility. The patient does not 
require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injections (J7325). 
 
You asked the Plan to pre-approve Synvisc-One. You say that Synvisc-One is medically necessary. The Plan 
denied your request. The Plan says a trial of Orthovisc and Monovisc is required before alternatives can be 
considered. 
 
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 Synvisc-One. Our reviewer says that 
Synvisc-One is not medically necessary. Our physician reviewer found the record shows no 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One injections (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a denture adjustment (D5410). 
 
You asked the Plan to pre-approve the dental service. You say that this service should be covered. You also say 
that you do not know why it is not covered. The Plan denied your request. The Plan says denture adjustment 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. 
 
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 
denture adjustment (D5410).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3310), two core buildups, 
including any pins when required (D2950 x2), and a crown (D2740) for tooth #11. 
 
You asked the Plan to pre-approve the endodontic therapy, core buildups, and crown. The Plan denied your 
request. The Plan says endodontic therapy and core buildup are not covered services. The Plan also says that 
the crown for tooth #11 exceeds the benefit allowable. 
 
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, endodontic therapy and core buildup 
are not among those covered under this benefit. The contract clearly states that crowns are limited to once per 
tooth per 60 months. The record shows that you received a crown (D2751) on tooth #11 on July 29, 2019, and 
your crown benefit for tooth #11 has been exhausted. Therefore, we decided that the Plan does not have to pre-
approve endodontic therapy (D3310), two core buildups, including any pins when required (D2950 x2), and a 
crown (D2740) for tooth #11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740) for tooth # 5. 
 
You asked the Plan to pre-approve the dental service. You say that you are in a lot of pain. You say that your 
dentist advised it is an important part of the treatment of the dental nerve. You also say that if this services is 
not approved then you cannot get the treatment that you need. The Plan denied your request. The Plan says 2 
crowns per calendar year are covered. The Plan also says that the frequency limit has been reached. 
 
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 and crowns are a covered service, the 
frequency limit of 2 per calendar year has been reached. The record shows that the Plan paid for 2 crowns that 
you received on August 24, 2020. Therefore, we decided that the Plan does not have to pre-approve a crown 
(D2740) for tooth # 5.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to hold you harmless for the polishing of the glasses received on July 25, 2020. 
 
You asked the Plan to pay for polishing of the glasses. You say that you were not aware there was a charge to 
polish your glasses. The Plan denied your request. The Plan says that the services received are not a covered 
benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The Plan follows these rules. 
 
You received the polishing of the glasses by a contract provider. The file does not show that the Plan provided 
notice that polishing of the glasses would not be covered. Under Medicare rules, this means polishing of the 
glasses is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for 
polishing of the glasses received on July 25, 2020.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two alveoloplasties not in conjunction with extractions, 
first 15 minutes of deep sedation/general anesthesia, and each subsequent 15 minute increment of deep 
sedation/general anesthesia. 
 
You asked the Plan to pre-approve the alveoloplasties and deep sedation/general anesthesia services. The Plan 
denied your request. The Plan says these services are not covered under your benefit package. 
 
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 
alveoloplasties not in conjunction with extractions, first 15 minutes of deep sedation/general anesthesia, and 
each subsequent 15 minute increment of deep sedation/general anesthesia.
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical 
records provided you do not require an intensive inpatient rehabilitation therapy program. There is no 
documentation that you require the intensive rehabilitation therapy program provided in an IRF. Care at the 
skilled nursing facility level appears to be more appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.