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

 
We decided that the Plan has to pre-approve a crown (D2750) for tooth #8. 
 
You asked the Plan to pre-approve the crown. You say that you advise a crown be placed on tooth #8 now that 
it has been treated endodontically. The Plan denied your request. The Plan says that it is not possible to 
determine if there is major decay or fracture present from the non-diagnostic x-ray that was submitted. 
 
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 crown 
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 crown. Our reviewer says that this 
service is medically necessary. Our physician reviewer found the criteria for coverage for a crown (D2750) for 
tooth #8 have been met due to the significant coronal breakdown. 
 
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 crown have been met. Therefore, we decided that the Plan has to pre-
approve a crown (D2750) for tooth #8.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided on March 27, 2020. 
 
You asked the Plan to waive the copayment for injection. You say that you have never been charged cost-
sharing for drugs in the past. The Plan denied your request. The Plan says the copayment 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $50 
copayment for injection administered by a provider.  
 
You have been asked to pay the allowed amount of $6.24, which is less than the $50 copayment for injection. 
Injection falls 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 copayment for an injection provided on March 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2020) progressive lenses (V2781)  
polycarbonate lenses (V2784) tint, photochromatic lenses (V2744) provided March 9, 2020. 
 
You asked the Plan to pay for the vision services. You say that you called prior to getting the services and was 
told this would covered. You feel that progressive lenses should be covered under the eyewear benefit. The 
Plan denied your request. The Plan says this service is not covered under the plan benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when purchased after cataract surgery. 
 
 
 
 
 
We looked at the file and the Plan's rules. Eyewear is covered when purchased after cataract surgery. Based on 
this information, we decided that the Plan's rules for coverage of the vision services have not been met. 
Therefore, we decided that the Plan does not have to pay for deluxe frames (V2020) progressive lenses 
(V2781)  polycarbonate lenses (V2784) tint, photochromatic lenses (V2744) provided March 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 22, 
2019 through October 31, 2019. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that in less than twenty-four 
(24) hours after being discharged from a knee replacement you had a stroke and went back to the emergency 
room. You state that you should not have to pay another copayment. The Plan denied your request. The Plan 
says the claim was processed accordingly with your 2019 EOC benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received inpatient hospital care from October 22, 2019 through October 31, 
2019. Since you had almost met your 2019 maximum-out-of-pocket (MOOP) cost, you were only assessed 
$429.93 which is the amount that took you to $3,200 and not, the full amount that would have been due had 
you been assessed the maximum per day/stay cost. 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 
inpatient hospital care from October 22, 2019 through October 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from March 4, 2020 to 
March 6, 2020. 
 
You asked the Plan to pay for the self-administered drugs. You say that you switched plans because you 
believed your current plan would pay for everything. The Plan denied your request. The Plan says these are 
self-administered drugs, and are not covered under 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 pay for the self-administered drugs 
provided from March 4, 2020 to March 6, 2020.  
 
Benefits for the self-administered drugs 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan 200mg tablet for the enrollee.
You asked the Plan to pre-approve the tablet. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xifaxan 200mg tablet for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) and suspension sleeve (L2397) to the
enrollee on January 17, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the orthosis have not been met. The documentation submitted did
not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot
be verified. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) and suspension
sleeve (L2397) to the enrollee on January 17, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 7, 2020. You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care. 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 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 did not pre-approve the service 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 out of network physician services provided to the enrollee on April 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings are needed for bilateral varicose veins. The Plan denied your request. The Plan says they do not meet the statutory definition of a dressing. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Knee orthosis (L1851) Ankle foot orthosis (L1971) 
suspension sleeve (L2397) and prefabricated, off-the-shelf foot, plastic, heel stabilizer (L3170) provided March 
25, 2020. 
 
You asked the Plan to pay for the orthoses. You say that the medical records provided will show proof of 
medical necessity. The Plan denied your request. The Plan says the documentation does not identify the 
enrollee's originating site at the time of the telehealth visit, there is no evidence of an established relationship 
between the enrollee and the ordering physician, there was no claims submitted for an evaluation and 
management service and there is no evidence of a prior telehealth service with the ordering physician as 
required per CMS guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
A review of the file does not show that the telehealth service was provided in an authorized originating site. 
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute 
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are 
likewise noncovered. Therefore, we decided that the Plan does not have to pay for Knee orthosis (L1851) 
Ankle foot orthosis (L1971) suspension sleeve (L2397) and prefabricated, off-the-shelf foot, plastic, heel 
stabilizer (L3170) provided March 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the zoster (Shingles) vaccine, intramuscular injection
(90750) and Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) provided on January
16, 2020.
You asked the Plan to pay for the vaccines provided under Medicare Part B. You say that these vaccines should
be covered by the Plan. The Plan denied your request. The Plan says the vaccines are covered under Medicare
Part D and are not covered under Medicare Part B.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccines
provided under Medicare Part B. The Plan follows the same rules.
The vaccines provided are not covered under the Part B benefit and should be submitted to your Medicare Part
D carrier for payment. Therefore, we decided that the Plan does not have to pay for the zoster (Shingles)
vaccine, intramuscular injection (90750) and Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap)
(90715) provided on January 16, 2020.
Benefits for the vaccines 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: Favorable

 We decided that the Plan has to pre-approve Entyvio. 
 
You asked the Plan to pre-approve the Entyvio. You say that the records provided support the need for the drug 
in dispute. The Plan denied your request. The Plan says that there is no generally accepted medical evidence 
that indicates the drug is beneficial for the enrollee's indication. 
 
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 the Entyvio. Our reviewer says that 
Entyvio is medically reasonable and necessary. Our physician reviewer found the enrollee was diagnosed with 
Crohn's disease complicated by C.difficile and anal stenosis. Treatment has necessitated ileocolectomy, 
hemorrhoidectomy and fissurectomy, and such interventional procedures as Botox chemodenervation of the 
anal sphincter for anal fissure management. The enrollee has required pulse prednisone, suffered liver toxicity 
with 6-mercaptopurine, and failed sulfasalazine, Humira and more recently Cimzia due to development of drug 
antibodies. The enrollee has been maintained since January 18, 2018 on Entyvio 300mg every 8 weeks with 
initially excellent response. However, per a September 20, 2019 chart entry, the enrollee was deemed "not in 
clinical remission" associated with a low serum drug level of 4.7ug/mL. No drug antibodies were detected. The 
provider recommended at that time Entyvio dose optimization to every 4 weeks. The clinical benefits of 
Entyvio continued with long-term treatment, regardless of prior TNF antagonist exposure. Increased dosing 
frequency might improve outcomes in patients who lose response to conventional 8-weekly dosing. Given the 
specialty-society guidance and expert-based literature above, Entyvio 300mg every 4 weeks is considered 
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 the Entyvio have been met. Therefore, we decided that the Plan has to pre-
approve Entyvio.  
 
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: 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 services are 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, 
medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary 
approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services 
but does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee 
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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is considered experimental and investigational.
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 services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this is an experimental/investigational procedure. The peer reviewed literature does not support RFA at
this time. The request is deemed not medically reasonable or 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve sacroiliac joint radiofrequency ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient clinic services (36415, G0463) provided on 
December 16, 2019. 
 
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says these services were not emergent or pre-authorized. There were 
network providers available. 
 
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 outpatient clinic services (36415, G0463) 
provided on December 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avastin/Oxaliplatin/Ondansetron Oral/Palonestron/Dexamethasone for the enrollee.
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your request. The Plan says the Medicare-approved sources do not support this regimen.
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 the drugs. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found the enrollee has an epithelial ovarian cancer currently on bevacizumab with progression. The combination of oxaliplatinand bevacizumab (avastin) is not FDA approved, supported by major drug compendia for off label use, or the medical literature. 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 the drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Avastin/Oxaliplatin/Ondansetron Oral/Palonestron/Dexamethasone for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network mental health services provided to the 
enrollee on March 12, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
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 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 did not pre-approve the service 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 out of network mental health services provided to the enrollee on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on January 6, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the proof of delivery was invalid.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery, which support medical necessity for the supplies provided in this case. The proof of delivery was not signed by the enrollee so it cannot be proven the enrollee received it. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on January 6, 2020.