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

 
We decided that the Plan has to pre-approve Rituximab. 
 
You asked the Plan to pre-approve the Rituximab. You say that the enrollee would benefit most from a regimen 
with the requested drug, and would have the least risk of side effects. You say that the enrollee's biopsy and lab 
findings show significant proteinuria as well as progressive renal dysfunction. The Plan denied your request. 
The Plan says that the requested drug does not meet the medical necessity criteria and would be considered 
investigational and experimental. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Rituximab. Our reviewer says that 
the criteria for coverage have been met. Our physician reviewer found the enrollee has membranous 
nephropathy. The requested use of Rituximab is FDA-approved for this diagnosis. Our physician reviewer 
found that this requested drug is considered the standard of care and treatment for the enrollee's disorder. 
 
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 Rituximab have been met. Therefore, we decided that the Plan has to pre-
approve Rituximab.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery pack (A9270). 
 
You asked the Plan to pre-approve a battery pack. You say that you need this for use with your continuous 
positive airway pressure machine. The Plan denied your request. The Plan says this item is not primarily 
medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a battery pack (A9270).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair life. 
 
You asked the Plan to pre-approve a stair lift. You say that you would like reconsideration because Medicare 
covers stair lifts. The Plan denied your request. The Plan says Medicare does not cover a stair lift. 
 
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 life.
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 the office visit. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says you do not have out-of-network 
benefits and the requested provider is out-of-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 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional physical therapy visits to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve additional physical therapy visits. You say that in-network providers are 
only having phone appointments. You say that services you need are impossible with a phone appointment. 
The Plan denied your request. The Plan says services are available in-network. The Plan also says that if the 
records indicate the in-network provider is unable to provide the necessary care, out-of-network services will 
be authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
additional physical therapy visits to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs procedure coded as 33289 and C2624. 
 
You asked the Plan to pre-approve a CardioMEMs procedure.. You say that because the plan has no coverage 
criteria on cardiac hemodynamic monitoring, you are requesting prior authorization for this procedure based on 
the enrollee meeting FDA approved labeling. The Plan denied your request. The Plan says this is considered 
investigational and only covered if being performed as part of a clinical trial. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that experimental and investigational devices are not covered. 
 
We looked at the file and Medicare rules. CardioMEMs procedures are considered investigational and only 
covered as part of a clinical trial. You are not having the procedure as part of a clinical trial. Based on this 
information, we decided that Medicare rules for coverage of a CardioMEMs procedure. have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a CardioMEMs procedure coded as 33289 
and C2624.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient level of care for the approved spinal surgery. 
 
You asked the Plan to pre-approve inpatient level of care for the approved spinal surgery. You say that the 
requested inpatient level of care for the approved spinal surgery is medically necessary. The Plan denied your 
request. The Plan says the requested inpatient level of care for the approved spinal surgery is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve inpatient level of care for the approved 
spinal surgery. Our reviewer says that the requested inpatient level of care for the approved spinal surgery is 
not medically necessary. Our physician reviewer found the enrollee is diagnosed with spondylosis with 
radiculopathy and intervertebral disc degeneration. The plan approved the requested back surgery but is 
denying an inpatient level of care for the approved surgery. The lumbar fusion surgery may be safely 
performed as an outpatient or with an observational level of stay. Inpatient admission is not medically needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient level of care for the approved spinal surgery have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient level of care for the approved spinal 
surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing for 4 or more teeth 
per quadrant (D4341) for all 4 quadrants. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee requires periodontal scaling 
and root planing for all 4 quadrants due to severe supragingival calculus and moderate subgingival calculus. 
The Plan denied your request. The Plan says the requested periodontal scaling and root planing is not medically 
necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the dental 
services when the services are medically necessary and reasonable.  
 
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 dental services. Our reviewer says 
that the periodontal scaling and root planing for all 4 quadrants is not medically necessary. Our physician 
reviewer found. The reviewer found that there is minimal, if any, bone loss seen in any quadrant. The code 
requested is D4341 for each quadrant, which are reserved for those situations where four or more teeth in a 
quadrant are involved and show bone loss. In a situation where there is increased pocketing and inflammation, 
the cause is often caused by a gingivitis and not a periodontitis condition which is not treated by scaling and 
root planing. Therefore, the requested services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planing for 4 or more teeth per quadrant (D4341) for all 4 
quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upper and lower partial denture. 
 
You asked the Plan to pre-approve the upper and lower partial denture. You say that your gums are hurting and 
continue to bleed. You say that you need the dentures to chew food. The Plan denied your request. The Plan 
says dentures are not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
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 the 
upper and lower partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction (D7210) for tooth # 20. 
 
You asked the Plan to pre-approve the dental service. You say that  The Plan denied your request. The Plan 
says the documentation does not support the service that was requested. The Plan also says that the requested 
service is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the dental 
service when the services are medically necessary and reasonable.  
 
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 dental service. Our reviewer says 
that the requested surgical extraction is not medically necessary. Our physician reviewer found the 
documentation provided was not adequate to determine the need for this service. The reviewer found the x-rays 
that were provided do not show tooth # 20 and therefore the need for a surgical extraction could not be made. 
 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental service have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a surgical extraction (D7210) for tooth # 20.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you have knee pain and cannot drive far. The 
Plan denied your request. The Plan says the requested services are available within your 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. The Plan has contract providers located within 
reasonable distance and travel time from your home. 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 physical 
therapy services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drug testing. 
 
You asked the Plan to pre-approve drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the documentation does not support why the requested services 
are necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that drug testing is only covered for certain 
indications.  
 
We looked at the file and Medicare rules. Review of the fil does not support why the requested testing is 
needed. Based on this information, we decided that Medicare rules for coverage of drug testing have not been 
met. Therefore, we decided that the Plan does not have to pre-approve drug testing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the bilateral breast ultrasound (76641) 
provided on February 20, 2020. 
 
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment was applied correctly to the 
service provided. 
 
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 $110 
copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a 
physician?s office or at a freestanding facility.  
 
You have been asked to pay a $106.78 copayment for the in-network radiological diagnostic service provided. 
This amount is less than the applicable copayment for this service. 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 the bilateral breast ultrasound (76641) provided on February 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) for tooth # 15. 
 
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says core build 
up is not listed as 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build 
up (D2950) for tooth # 15.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 1 power wheelchair with accessories. 
 
You asked the Plan to pre-approve power wheelchair. You say that you are appealing. The Plan denied your 
request. The Plan says the denial of authorization for this device is correct, because the enrollee is ambulatory 
and successfully uses a manual wheelchair, and there is no evidence to support the need for a power 
wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our reviewer says 
that the enrollee does not meet the Medicare criteria for the requested power mobility device. Our physician 
reviewer found the documentation reveals a personal mobility deficit but does not reveal that the deficit impairs 
participation in mobility-related activities of daily living (MRADLs) in the home or a clear gait/neuromuscular 
examination that indicates why the enrollee's mobility deficit cannot be helped by a walker or manual 
wheelchair. The documentation reveals no in-person assessment in the enrollee's home to evaluate that he can 
safely maneuver this power mobility device and the documentation is not clear - given his vision deficits - that 
he can safely maneuver a power mobility device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Group 1 power wheelchair with accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported crown (D6066), the surgical 
placement of an implant body (D6010), and a prefabricated abutment (D6056). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says implant 
supported crown is not listed as a covered service. The Plan says surgical placement of an implant body is not 
listed as a covered service. The Plan also says prefabricated abutment 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 dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an 
implant supported crown (D6066), the surgical placement of an implant body (D6010), and a prefabricated 
abutment (D6056).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cystoscopy (52000) and non-covered 
self-administered drug (A9270) provided May 29, 2020. 
 
You asked the Plan to waive the copayment for the cystoscopy and non-covered self-administered drug. You 
say that you do not know why your doctor would refer something that was not covered. You do not have $300 
to pay this bill. You are on disability. The Plan denied your request. The Plan says the claim was processed 
with the correct 50% out-of-network coinsurance applied. The self-administered drug has also been paid. 
 
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 50% 
coinsurance for out-of-network outpatient hospital surgery services.  
 
You have been asked to pay $307.53 for the cystoscopy and non-covered self-administered drug. The 
cystoscopy and non-covered self-administered drug falls within the Outpatient hospital 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 the cystoscopy (52000) and non-covered self-
administered drug (A9270) provided May 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950). 
 
You asked the Plan to pre-approve the dental service. You say that you were advised the service was not 
needed. You also say that you were advised that a root canal was needed first and then the crown. The Plan 
denied your request. The Plan says core build up 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build 
up (D2950).