Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that this is the only provider that can come to your 
home. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 
a referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical extraction of erupted tooth (D7210) and 
anesthesia services (D9222, D9223). 
 
You asked the Plan to pre-approve the surgical extraction of erupted tooth and anesthesia services. You say that 
these services are medically necessary. The Plan denied your request. The Plan says these services are not 
covered under your benefit plan. 
 
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 
surgical extraction of erupted tooth (D7210) and anesthesia services (D9222, D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is a network provider that is geographically closer than the requested 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 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 
a referral to an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for cataract surgery provided on August 25, 
2020. 
 
You asked the Plan to waive the deductible for cataract surgery. You say that you are upset that this has applied 
to your deductible. The Plan denied your request. The Plan says the deductible amount you are being charged is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $750 deductible for cataract surgery in an ambulatory surgical center. 
At the time this claim was processed, $0 of the $750 deductible had been met. The allowed amount of the claim 
is $539.61, resulting in a deductible obligation of $539.61. 
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient 
Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible for 
Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical 
Centers. This cost sharing is a contractual obligation that had not been met at the time cataract surgery was 
received on August 25, 2020. Therefore, we decided that the Plan does not have to waive the deductible for 
cataract surgery provided on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on August 
12, 2020. 
 
You asked the Plan to pay for the dental service. You say that there was nothing special or extra that was done 
for this visit. You also say that for the $158 charge, you feel that your responsibility of $90 is excessive for a 
routine cleaning. The Plan denied your request. The Plan says periodontal maintenance 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 pay for the 
periodontal maintenance (D4910) provided on August 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve inpatient psychiatric hospitalization. You say that you need additional 
inpatient services. The Plan denied your request. The Plan says you can be treated in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 psychiatric hospitalization. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found it did not appear 
that the services for the dates in question were reasonably expected or medically necessary to improve the 
patient?s condition or for the purpose of diagnosis.  
 
This patient was treated by an individualized treatment plan and alluded to in the record. It appears that the 
services were supervised and evaluated by a physician. Based upon review the records provided, this patient 
does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in 
question of November 30, 2020, forward and could have been treated in a lesser restrictive setting as the 
enrollee was not showing any suicidal or homicidal ideation (passive death wish), auditory or visual 
hallucinations and was not showing any behaviors being cooperative and compliant. 
 
 
 
 
 
 
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 psychiatric hospitalization have not been met. Therefore, we decided 
that the Plan does not have to pre-approve inpatient psychiatric hospitalization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitoring system 
for the enrollee. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the Medicare coverage criteria. 
 
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 system. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee is noted to have type II diabetes, for which she takes oral medications and a set dose of 
mixed insulin. How often the enrollee was testing her blood glucose prior to using a CGM is not documented 
(i.e. BG log), but the enrollee is ordered to test her blood glucose twice daily in the absence of a CGM. There is 
no evidence that the enrollee uses the results of blood glucose testing to self adjust insulin doses multiple times 
per day. As such, the requested CGM is not shown to be medically necessary or reasonable. 
 
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 system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitoring system for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (Q5106). 
 
You asked the Plan to pre-approve Retacrit. 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 Retacrit. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found erythropoiesis-stimulating agents such as 
retacrit have generally not been successful in alleviating anemia associated with myelofibrosis. Generally, 
Danazol is first line and this enrollee has not yet tried this line of therapy. The service is not reasonable or 
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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit (Q5106).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH service is medically 
necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found you are receiving appropriate care at the present acute care hospital. You do not 
require services at the LTACH that are not available at the acute care hospital where you are currently 
receiving care. There are no services available at the LTACH that you require that are not available at the 
health care setting being offered by the health plan. The requested LTACH services are not medically 
necessary, reasonable, and appropriate for your diagnosis and condition and are able to be furnished safely and 
effectively only on an inpatient basis. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, tooth 9 (D2950) crown, tooth 9 (D2752). 
 
You asked the Plan to pre-approve the dental services. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says these services are not covered 
under the plan benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup, tooth 9 (D2950) crown, tooth 9 (D2752).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve retreatment of previous root canal therapy. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not covered under the enrollee's 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 
retreatment of previous root canal therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor. 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for this device is correct, 
because the records do not show that the enrollee meets all of the required criteria. 
 
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 continuous glucose monitor. Our 
reviewer says that the enrollee does not meet the Medicare criteria for the requested continuous glucose 
monitor. Our physician reviewer found according to the documentation the enrollee is maintained on a fixed 
dose of Novolog. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuous glucose monitor have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve proton beam therapy. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the use of proton therapy is an accepted 
radiation technology that has proven efficacy and tolerability. It is therefore not investigational, as it is simply 
another means to deliver radiation. There are published studies on the use of proton therapy for head and neck 
cancer, although proton therapy is not an accepted standard. Based on the information provided showing an 
unacceptable intensity-modulated radiation therapy (IMRT) plan, a proton plan can be considered medically 
necessary as it would meet ASTRO model policy guidelines and the NCCN criteria based on the IMRT plan 
not meeting constraints. Therefore, it is plausible that proton therapy would provide a clinically meaningful 
benefit over a well-designed IMRT plan, and it would be furnished in accordance with accepted standards of 
medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve proton beam therapy.  
 
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 transfer bench. 
 
You asked the Plan to pre-approve these services. You say that you cannot use the bath or shower without 
assistance. The Plan denied your request. The Plan says the services are not covered. 
 
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 transfer bench.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for cataract surgeries and does not have to 
waive the coinsurance for Medicare Part B drugs provided on May 27, 2020, and June 24, 2020. 
 
You asked the Plan to waive the copayments for cataract surgeries and to waive the coinsurance for Medicare 
Part B drugs. You say that you disagree with the charges and feel that you are being overcharged for the 
surgeries. The Plan denied your request. The Plan says the claims were processed correctly and you are being 
charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for outpatient surgery, including services provided at hospital outpatient facilities. Your contract 
with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. 
 
You received a cataract surgery and a Medicare Part B drug on May 27, 2020. Therefore, you are responsible 
to pay a $250 copayment for the cataract surgery. The allowed amount for the Medicare Part B drug is $444.49 
and 20% of that is $88.90.   
 
You received a cataract surgery and a Medicare Part B drug on June 24, 2020. Therefore, you are responsible 
to pay a $250 copayment for the cataract surgery. The allowed amount for the Medicare Part B drug is $444.49 
and 20% of that is $88.90.   
 
The total amount you owe is: $677.80.  
 
You have been asked to pay the total amount you owe is: $677.80 for cataract surgeries and Medicare Part B 
drugs. Cataract surgeries fall within the outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers benefit category. Medicare Part B drugs fall within the Medicare Part 
B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for cataract surgeries 
and does not have to waive the coinsurance for Medicare Part B drugs provided on May 27, 2020, and June 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pre-diagnostic test, core buildup, and pulp cap. 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the services 
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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a pre-
diagnostic test, core buildup, and pulp cap.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral for an MRI cervical spine at an out-of-network 
provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are in-network providers that can provide this service. 
 
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 
a referral for an MRI cervical spine at an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on September 17, 2020, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained. The 
Plan says that the member's primary care physician did not refer these services. 
 
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 physician services provided on September 17, 
2020, by an out-of-network (OON) provider.