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

 
We decided that the Plan does not have to pre-approve dentures (D5110, D5120). 
 
You asked the Plan to pre-approve the dentures. You say that new dentures are medically necessary. The Plan 
denied your request. The Plan says your benefit for dentures has been exhausted. 
 
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 benefit for dentures has been 
exhausted. The plan covers one set of dentures every 5 years. The record shows a set was provided on May 17, 
2016. Therefore, we decided that the Plan does not have to pre-approve dentures (D5110, D5120).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cologuard test. 
 
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your 
request. The Plan says this test is not indicated in patients over the age of 85. 
 
The Plan must follow Medicare rules. Medicare rules say that Cologuard is not covered for enrollees over age 
85. 
 
You are 89 years old. Based on this information, we decided that Medicare rules for coverage of the test have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a Cologuard test.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lumigan eye drops. 
 
You asked the Plan to pre-approve the Lumigan eye drops.. You say that since starting Lumigan, the enrollee's 
intraocular pressures have reduced and been kept stable. You also say that you recommend the enrollee 
continue using these drops to prevent progression with glaucoma. The Plan denied your request. The Plan says 
this drug is not covered for the enrollee's condition 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 Lumigan eye drops.  
 
Benefits for Lumigan eye drops. 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 pay for out of network chiropractic services. 
 
You asked the Plan to pay for out of network providers. You say that you prefer to see the out of network 
provider. The Plan denied your request. The Plan says this service can be provided in network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 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 out of network chiropractic services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is 
not covered. 
 
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 
core buildup, including any pins when required (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra test strips. 
 
You asked the Plan to pre-approve the strips. You say that this is medically necessary. The Plan denied your 
request. The Plan says this brand is non-formulary. 
 
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 strips. Our reviewer says that the 
requested brand is not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no documentation that there is a medical necessity for OneTouch Ultra brand of test strips rather 
than the health plan's preferred product, True Metrix brand test strips. 
 
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 strips have not been met. Therefore, we decided that the Plan does not have 
to pre-approve OneTouch Ultra test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery for a continuous positive airway 
pressure (CPAP) device. 
 
You asked the Plan to pre-approve the backup battery. You say that this battery is necessary due possible 
power outages or lack of electrical access. The Plan denied your request. The Plan says this is not considered 
durable medical equipment and cannot be covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose and not duplicate the purpose of another item.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Although this 
alternate power source may be appropriate, it does not directly treat an illness. It also duplicates that function of 
the power adapter built into the CPAP device. Therefore, we decided that the Plan does not have to pre-approve 
a backup battery for a continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hoveround heavy duty power wheelchair(K0824). 
 
You asked the Plan to pre-approve the power wheelchair. You say that your current scooter is too small. The 
Plan denied your request. The Plan says the current scooter was issued in 2018 and is in the same size class as 
the requested scooter. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a Jazzy Heavy Duty power wheelchair. A Jazzy Heavy Duty power wheelchair 
serves the same purpose as the requested power wheelchair.  Both units are in the same weight class. The 
current chair is less than 5 years old. The record does not show that it is irreparably damaged or otherwise 
unable to be used. Therefore, we decided that the Plan does not have to pre-approve a Hoveround heavy duty 
power wheelchair(K0824).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Keytruda. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found the enrollee has adenocarcinoma of unknown origin that has PDL1 expression of 30 and is 
microsatellite stable. The requested use of Keytruda is not FDA approved. The use is not supported in any of 
the CMS approved compendia. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
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 the records do not indicate that there are significant, or complex medical/nursing 
issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and 
other medication management, wound care, and daily therapy can be provided at a SNF. The member is mostly 
TOTAL/MAX assist for functional transfers and activities of daily living (ADLs) and a less intensive, longer 
duration of therapy may be more appropriate. It is not clear the member would be able to fully benefit and/or 
participate in an IRF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ankle-foot orthosis (L4396). 
 
You asked the Plan to pre-approve the orthosis. You say that the orthosis is medically necessary. The Plan 
denied your request. The Plan says rules for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that ankle-foot orthoses are covered when 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 the orthosis. Our reviewer says that the 
orthosis is not medically necessary. Our physician reviewer found pre-treatment passive range of motion has 
not been measured with a goniometer and documented in the medical record. Furthermore, documentation does 
not support that there is a reasonable expectation of the ability to correct the contracture, that the contracture is 
interfering with the beneficiary's functional abilities and that the brace will be used as a component of a therapy 
program. 
 
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 pre-approve an ankle-foot orthosis (L4396).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that you have not received a concrete evidence-
based justification for the denial. The Plan denied your request. The Plan says this is not 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 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 
core buildup, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tertiary level of care. 
 
You asked the Plan to pre-approve tertiary level of care. You say that the requested tertiary level of care is 
medically necessary. The Plan denied your request. The Plan says the requested tertiary level of care is not 
medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 tertiary level of care. Our reviewer says 
that the requested tertiary level of care is not medically necessary. Our physician reviewer found the enrollee 
sustained traumatic burns in 2016 requiring autografts and allografts with complaints of persistent pain without 
documentation of any skin breakdown or wounds, neuropathic (burning shooting pain with numbness and 
tingling).  
 
There is no medical justification for why the enrollee cannot be evaluated in an in network non-tertiary level 
wound specialist when there is no evidence of any wound or graft issues. There are available in network 
providers available to evaluate 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 tertiary level of care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve tertiary level of care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all lower extremity prostheses, flex-walk system or 
equal (L5981) and an all lower extremity prostheses, multi-axial rotation unit (L5986) for the enrollee. 
 
You asked the Plan to pre-approve these items. You say that the enrollee is a K3 ambulator and these items are 
medically necessary. The Plan denied your request. The Plan says that there is no clinical documentation from 
the member's medical record that supports that K3 components are reasonable and 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 these items. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. The requested 
prosthetic parts are not supported above a standard below knee amputee prosthesis for the enrollee who has not 
shown an ability to perform K3 functional ambulation and activities. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these items. 
 
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 items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an all lower extremity prostheses, flex-walk system or equal (L5981) and an all lower 
extremity prostheses, multi-axial rotation unit (L5986) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ultracet tab 37.5-325 for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested medication is denied as a benefit exclusion. 
 
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 Ultracet tab 37.5-325 for 
the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the EGD, flexible, transoral; with biopsy, single or 
multiple (CPT Code 43239). 
 
You asked the Plan to pre-approve the EGD. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the documentation fails to indicate that the member has any current 
symptoms. 
 
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 EGD. Our physician reviewer found 
the enrollee does not meet the medically necessary indications for EGD at this time. The LCD criteria are not 
met; denial is upheld. 
 
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 EGD have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the EGD, flexible, transoral; with biopsy, single or multiple (CPT Code 43239).
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 patient meets inpatient criteria and would benefit 
from acute inpatient rehab that cannot be accomplished at a lower level of care. 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for tracheosotmy for obstructive esophageal cancer. Medical problems are stable. There are no 
complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including 
either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 
record supports a need for physical and occupational therapy, it does not support a need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that this patient will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: 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 you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee has been in a skilled 
nursing facility (SNF) since September 2, 2020 after right pelvic and right wrist fractures. Ongoing 
management has included pain control with analgesics. She is currently hemodynamically stable and needs 
modified to maximal assistance with care. She has no complex medical, nursing, or rehabilitation needs that 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may 
benefit from further therapy but does not require an intensive therapy program in an IRF. 
 
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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga 5mg tablets. 
 
You asked the Plan to pre-approve the Farxiga tablets. You say that this medication is necessary as supported 
by the records submitted. The Plan denied your request. The Plan says this oral drug is not 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 Farxiga 5mg tablets.  
 
Benefits for the Farxiga 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.