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

 
We decided that the Plan does not have to pay for the medical services provided on March 25, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for practitioner services. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on March 25, 2020 
by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the Keytruda. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says Keytruda is not proven to be effective for 
the treatment of this member's condition. 
 
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 Keytruda. Our reviewer says that 
this therapy regimen does not meet criteria per the compendia. Our physician reviewer found this is a second 
line therapy. 
 
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 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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.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. The complexity of your nursing, medical and rehabilitation needs do not require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. You continue to have a need for skilled therapy with ongoing safety concerns and a potential for functional improvement, however, the documentation doesn't support that you would meet criteria for admission to an acute inpatient rehabilitation facility. There is no indication that you would require skilled rehabilitation in an IRF, participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain your functional status. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a partial lower denture (D5212). 
 
You asked the Plan to pre-approve the dental item. You say that you need the partial dentures. The Plan denied 
your request. The Plan says that the requested lower partial denture would not be considered an essential 
service based on policy guidelines and plan benefit coverage. 
 
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 
item 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 item. Our reviewer says that 
the lower removable partial denture is medically necessary. Our physician reviewer found the provided 
documentation shows the enrollee is missing mandibular posterior teeth bilaterally. The reviewer found that 
lower removable partial denture is reasonable and necessary to provide good bilateral masticatory function. The 
reviewer found that a lower removable denture would prevent migration and extrusion of teeth into the 
edentulous mandibular areas. Therefore, the reviewer found that the requested lower removable partial denture 
is medically reasonable and 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 item have been met. Therefore, we decided that the Plan has to pre-
approve a partial lower denture (D5212).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro 2 Motion-G Powered Arm Brace (L8702, 
99499). 
 
You asked the Plan to pre-approve the brace. You say that the brace is medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
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 brace. Our reviewer says that the 
requested items are not considered medically reasonable and necessary in this case. Our physician reviewer 
found a review of the literature reveals additional controlled studies of the MyoPro arm brace for upper 
extremity paralysis after stroke are needed with larger patient groups, consistent improvements of relevant 
outcome functional measures, and long term follow up. The device is still considered investigational. 
 
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 brace have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a MyoPro 2 Motion-G Powered Arm Brace (L8702, 99499).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 10 additional extractions provided on September 19, 2019. 
 
You asked the Plan to pay for 10 additional extractions. You say that the provider didn't check thoroughly 
enough regarding coverage. You say that you wouldn't have agreed to the dental work if you knew the cost. 
The Plan denied your request. The Plan says you only have a benefit for 2 extractions every calendar year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of 2 
extractions per calendar year. The Plan paid for two extractions provided on September 19, 2019, which 
exhausted your benefit. Therefore, we decided that the Plan does not have to pay for 10 additional extractions 
provided on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the immediate upper denture (D5130) provided on July 6, 
2020. 
 
You asked the Plan to pay for the immediate upper denture (D5130). You say that your claim was denied 
because of dual insurance but you do not have dual insurance. The Plan denied your request. The Plan says the 
service is 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 pay for the 
immediate upper denture (D5130) provided on July 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth # 5 and retainer crowns 
(D6750) for teeth # 4 and 6. 
 
You asked the Plan to pre-approve the dental services. You say that you are really sad. You also say that you 
cannot eat well. The Plan denied your request. The Plan says the requested services are no 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 requested services are not medically necessary. Our physician reviewer found the provided 
documentation indicates that recurrent caries of an abutment retainer (tooth #4) requires removal of the crown 
and treatment of the caries. The reviewer found that coverage has been approved for the services needed to 
treat this along with approval of a removable appliance. The reviewer found that that the approved services are 
adequate in returning the enrollee to proper dental health and function. Therefore, the reviewer found that the 
requested services do not meet the criteria for coverage. 
 
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 a pontic (D6240) for tooth # 5 and retainer crowns (D6750) for teeth # 4 and 6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral x-ray (D0220) and the extraction (D7140) 
provided on June 1, 2020. 
 
You asked the Plan to pay for the dental services. You say that this was the only provider that could see in a 
timely matter due to Covid-19. You say that you were in pain. You say that you did not feel you could wait 2 
months to have your tooth pulled. You also say that you did not think to check if the provider was in network 
or not. The Plan denied your request. The Plan says the provider in this case is not an in network provider. The 
Plan says care rendered by a provider that is not part of the supplemental dental network 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 dental services you received are not 
among those covered under this benefit when you receive them out of network. Therefore, we decided that the 
Plan does not have to pay for the intraoral x-ray (D0220) and the extraction (D7140) provided on June 1, 2020.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room (ER) services you 
received on July 12, 2020. 
 
You asked the Plan to waive the copayment for the ER services. You say that you received a CT scan and it 
was determined that you had an enlarged gall bladder, 2 kidney stones and a hernia.  You say that all of these 
things contributed to your stomach problems, so this charge should be reconsidered. The Plan denied your 
request. The Plan says you were charged this copayment correctly. 
 
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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for the ER services. 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 emergency room (ER) services you received on July 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on June 8, 2020. 
 
You asked the Plan to pay for the dental services. You say that you knew the provider could no longer file 
claims. You say that you had surgery which resulted in your partial denture no longer fitting in your mouth. 
You also say that this provider was familiar with you and would therefore know just how to modify your 
denture to make it fit. The Plan denied your request. The Plan says the provider in this case does not participate 
with Medicare. The Plan says that services provided by an opt out provider are not payable. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This 
provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
the dental services provided on June 8, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 21, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
 
 
 
 
 
 
 
 
 
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the 
laboratory services provided on October 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the foot orthotics (L3020) provided on  
June 5, 2020. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this item is not a covered benefit for your 
condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to issue reimbursement for the foot orthotics 
(L3020) provided on June 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated ankle foot orthosis. 
 
You asked the Plan to pre-approve a custom fabricated ankle foot orthosis. You say that the requested custom 
fabricated ankle foot orthosis and additions are medically necessary. The Plan denied your request. The Plan 
says the enrollee does not meet criteria for a custom fabricated ankle foot orthosis. 
 
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 a custom fabricated ankle foot orthosis. 
Our reviewer says that the enrollee does not meet criteria for a custom fabricated ankle foot orthosis. Our 
physician reviewer found the enrollee is ambulatory but the documentation does not reveal clear indications on 
a physical exam why the enrollee requires a custom AFO or a prefabricated AFO potential to benefit 
functionally. The enrollee ambulates without the need for any assistive devices. The enrollee is noted to have 
normal muscle mass, can heel and toe walk with ease and arise from a seated position unassisted. There is no 
documentation of an objective range of motion deficits in degrees, a specific muscle motor exam or indications 
of which ankle/foot specific tests were used to indicate instability.  The documentation is not clear that this 
orthosis will be used for over 6 months, that it is needed to control the foot, ankle or foot in more than one 
plane, that there is a documented neurological, circulatory, or orthopedic status that requires custom fabricating 
over a model to prevent tissue injury or that the enrollee has a healing fracture which lacks normal anatomical 
integrity or anthropometric proportions. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a custom fabricated ankle foot orthosis have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a custom fabricated ankle foot orthosis.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services as part of a clinical trial. 
 
You asked the Plan to pre-approve services as part of a clinical trial. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve services as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve services as part of a clinical trial.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on July 9, 2020. 
 
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
chiropractic services. 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 chiropractic services provided on July 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea power seat lift chair.You asked the Planto pre-approvethe chair. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is only specifically indicated for people who cannot stand up from a chair.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.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 chair. Our reviewer says that the requested lift chair is not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal objective evidence of severe arthritis of the hip. The documentation does notreveal objective evidence of neuromuscular disease. The documentation does not support that this request is likely to effect improvement in your condition. The records do not indicate that you are completely incapable of standing from a chair in the home on a physical exam. The records indicate that you can ambulate.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 chair have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea power seat lift chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nervous system surgery (64999) provided on February 
26, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for nervous system surgery. You say that the services rendered were medically 
necessary. The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent 
services rendered by an out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the nervous system surgery (64999) provided on 
February 26, 2020 by an out of network (OON) provider.