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

 
We decided that the Plan does not have to waive the $300 copayment charged for ambulance transport 
provided on July 8, 2020. 
 
You asked the Plan to waive this copayment. You say that you did not feel you needed the ambulance 
transport, but the emergency responders insisted you go. The Plan denied your request. The Plan says this cost 
share was charged based on the services provided and the Plan contract agreement. 
 
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 $300 
copayment for ambulance transport. 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 $300 copayment charged for ambulance 
transport provided on July 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the immediate upper and lower denture and additional 
extractions. 
 
You asked the Plan to pre-approve the immediate upper and lower denture and additional extractions. You say 
that your teeth are obstructed and loose. You say that your gums are inflamed, bleeding and infected. 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, you also have a maximum benefit of 
one extraction per year. The Plan approved one extraction on August 26, 2020, which exhausted your benefit. 
Dentures are not covered benefits. Therefore, we decided that the Plan does not have to pre-approve the 
immediate upper and lower denture and additional extractions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you are not able to use the stairs safely and need 
to get to your shower. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve auryxia tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has tried other medications 
for which there has been no favorable result. The Plan denied your request. The Plan says the denial of 
authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not 
administer the enrollee's Medicare Part D prescription drug benefits. 
 
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 auryxia tablets.  
 
Benefits for self-administered 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegynecology services at a tertiary care center.You asked the Plan to pre-approvethe services. You say that you have been seeing the doctor at this facility since 2015 when they performed your hysterectomy. You state your previous authorization with this facility was good from December 19, 2019, through June 16, 2020, and the facility was supposed to request an extension on that authorization.The Plan denied your request. The Plan says based on review of the provider progress notes, there was no indication of why you need to continue your care at a tertiary care center. The Plan states they redirected you to a community level specialist who can provide the requested services.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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found tertiary care is not medically necessary and is only for patient preference. You can be transitioned to an in-network provider.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 not been met.Therefore, we decided that the Plan does not have to pre-approvegynecology services at a tertiary care center
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by an out-of-network provider on 
April 9, 2019. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing unpaid bills for services 
recommended by your primary care physician. The Plan denied your request. The Plan says the service requires 
prior authorization and there is insufficient information to determine medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider must submit sufficient information 
to confirm that coverage criteria have been met and to determine whether payment is due.
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for 
physical therapy provided by an out-of-network provider on April 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you require additional 
trips to get to dialysis appointments. The Plan denied your request. The Plan says that you have exceeded your 
benefit limit. 
 
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 Plan's coverage rules apply in this 
case. The Plan covers a maximum of sixty (60) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 16, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 genetic testing at issue in this appeal was 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 pay for the genetic 
testing provided on April 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you do not have good balance and has 
fallen in the past. You are afraid that you will fall again getting off of the toilet. The Plan denied your request. 
The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate, neither the Plan nor Medicare offers coverage 
of this item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Reyvow 50mg tablets. 
 
You asked the Plan to pre-approve the Reyvow tablets. You say that the enrollee has chronic migraines and has 
failed many other medications. The Plan denied your request. The Plan says this is an oral drug which cannot 
be covered by Medicare 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 Reyvow 50mg tablets.  
 
Benefits for the Reyvow 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 pre-approve a diagnostic cast (D0470), 5 retainer crowns (D6750), 
and 3 pontics (D6240). 
 
You asked the Plan to pre-approve the dental services. You say that the bridge for teeth # 20 to 23 would not 
provide adequate tooth support due to the fragile nature of tooth # 23. You say that tooth # 24 would need to be 
added for support. You say that tooth # 24 is already part of another bridge from tooth # 24 to 26 which has 
poor marginal adaptation and would benefit from being replaced as well. The Plan denied your request. The 
Plan says diagnostic cast is not listed as a covered service. The Plan says retainer crown are not listed as a 
covered service. The Plan says pontics are not listed as a covered service. The Plan also says services that are 
not listed are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans 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 
diagnostic cast (D0470), 5 retainer crowns (D6750), and 3 pontics (D6240).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the established outpatient office visit (99213) provided on 
March 17, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that no authorization is needed for payment of services 
rendered under telemedicine. The Plan denied your request. The Plan says prior authorization must be obtained 
for non-emergent services rendered by an out-of-network provider. 
 
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 established outpatient office visit (99213) 
provided on March 17, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dalbavancin (J0875). 
 
You asked the Plan to pre-approve Dalbavancin. 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. 
 
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 Dalbavancin. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the review has determined that the 
documentation does not support that the Dalbavancin is medically reasonable and necessary for the enrollee. 
The documentation does not support that the Dalbavancin 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 Dalbavancin have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Dalbavancin (J0875).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve20 total units of psychological testing for the enrollee.We note the Plan approved 10 units. You asked the Plan to pre-approve20 units of psychological testing. You say that this testing is medically necessary.The Plan denied your request. The Plan says themedical records submitted do not show the requested services are medically necessary. The Plan approved 5 units ofcpt code (96133) and 5 units of cpt code (96137) or 10 units' total. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Based on the medical records provided, the Plan has approved 10 of the 20 units of testing requested for evaluation of the enrollee. The medical records provided do not show the enrollee requires the total number of units requested at this time. Therefore, we decided that the Plan does not have to pre-approve20 total units of psychological testing for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the placement of a Interspinous Spacer (22869, 22870). 
 
You asked the Plan to pre-approve the procedure. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the device at issue is considered investigational at this time and is not 
covered. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Vertiflex Superion device is considered experimental in this application. 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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the placement of a Interspinous Spacer (22869, 22870).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional therapy visits. 
 
You asked the Plan to pre-approve 12 additional therapy visits. You say that additional therapy visits should be 
approved. The Plan denied your request. The Plan says additional visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 12 additional therapy visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the enrollee has had extensive therapy for this 
condition and were trained in an independent in a home exercise program. Our reviewer says that the unique 
skills of a professional therapist are not required to safely and effectively provide ongoing treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 additional therapy visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve 12 additional therapy visits.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
2, 2020 to April 30, 2020. 
 
You asked the Plan to pay for home health services. You say that you would like reconsideration because this 
claim is per visit and the services rendered were medically necessary. The Plan denied your request. The Plan 
says the claim was billed with type of bill code 323 which is not valid for per visit billing. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, the 
 
 
submitted claim was not billed with a valid type of bill code for home health services. Therefore, we decided 
that the Plan does not have to pay for the home health services provided to the enrollee from April 2, 2020 to 
April 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for nurse practitioner services provided on May 31, 2020. 
 
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says the 
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis 
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, 
which requires prior authorization from the plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 nurse practitioner services provided on May 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint (CPT Code 64633) 
and destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or 
CT); cervical or thoracic, each additional facet joint (CPT Code 64634). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the requested procedure is not supported in the records. 
 
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 physician reviewer 
found the records do not show that the provider confirmed facet joint pain with one of the following: 1) two 
medial branch blocks (MBB) that provided at least 80% improvement of the member's pain for the amount of 
time the analgesic was supposed to last or improve the member's daily activities and movement by 50% or 2) 
an injection done to treat the member's pain provided at least 50% relief for 3 months.  The review has 
determined that the medical records provided do not meet the requirements listed in the LCD for Medicare 
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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); cervical or thoracic, single facet joint (CPT Code 64633) and destruction by neurolytic 
agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each 
additional facet joint (CPT Code 64634).
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 the IRF care is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 there is concern that the patient will not be 
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
inpatient rehabilitation facility. 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 inpatient rehabilitation facility (IRF) admission and services.