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

 
We decided that the Plan does not have to pre-approve an all-white glass crown, tooth 3 (D2740). 
 
You asked the Plan to pre-approve a crown. You say that the service is medically necessary. The Plan denied 
your request. The Plan says discoloration, deformation, and/or attrition/abrasion/erosion/loss of vertical 
dimension does not fulfill the criteria for approval for a crown under this 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. The Plan covers a 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 a crown. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found a standard composite or amalgam restoration 
would be reasonable and therefore there is no medical necessity for a crown on tooth #3. 
 
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 a crown have not been met. Specifically, a lesser means of restoration is 
possible. This means the service is not reasonable or necessary. Therefore, we decided that the Plan does not 
have to pre-approve an all-white glass crown, tooth 3 (D2740).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network neurosurgeon. 
 
You asked the Plan to pre-approve these services. You say that you are in extreme pain and feeling numbness 
in your low back. 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 neurosurgeon.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone 30 mg tablet. 
 
You asked the Plan to pre-approve Oxycodone. You say that this service is medically necessary. The Plan 
denied your request. The Plan says this drug is not Medicare covered under the Part A or B benefit. 
 
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 Oxycodone 30 mg tablet.  
 
Benefits for Oxycodone 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is for help to alleviate pressure. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
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 pre-approve foot orthotics.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low-dose computed tomography (LDCT) scan. 
 
You asked the Plan to pre-approve a low dose CT scan. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says you do not meet criteria for the requested services. 
 
The Plan must follow Medicare rules. Medicare rules say that LDCT is only covered for enrollees between the 
ages of 55 and 77. 
 
We looked at the file and Medicare rules. Review of the file shows that you are 80 years old. You are not 
between the ages of 55 and 77. Based on this information, we decided that Medicare rules for coverage of a 
low dose CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a low-
dose computed tomography (LDCT) scan.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex). 
 
You asked the Plan to pre-approve Vertiflex. You say that this procedure would provide significant clinical and 
quality of life benefits for the enrollee. The Plan denied your request. The Plan says the denial of authorization 
for this service is correct, because research has not found this to be helpful for the enrollee's condition. 
 
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 Vertiflex. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is a lack of large volume, long-term peer-reviewed outcome studies to support the use of 
this device for the enrollee's condition. There was no advanced diagnostic imaging to address whether or not 
the enrollee has spinal stenosis. Contraindications have not been adequately addressed in the medical records. 
There is no discussion indicating that a dual-energy X-Ray absorptiometry (DEXA) scan has demonstrated no 
osteoporosis in the enrollee. Superion indirect lumbar decompression would not be considered the standard of 
care for the enrollee's medical condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have 
to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection. 
 
You asked the Plan to pre-approve SI joint injection. You say that this if the first thing that has helped alleviate 
your pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because a repeat SI injection is only medically necessary if the first injection provides at least 75% pain relief, 
but you only received 60% pain relief. 
 
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 SI joint injection. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found you received 60% pain relief from the first SI injection. However, a repeat SI joint 
injection is medically necessary if the first one provides at least 75% pain relief. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SI joint injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Facet Joint injections. 
 
You asked the Plan to pre-approve Facet Joint injections. You say that you need the injections to reduce your 
low back pain. The Plan denied your request. The Plan says coverage criteria for the requested Facet Joint 
Injections have 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 Facet Joint injections. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found in this case, the enrollee has evidence of radiculopathy and therefore does not meet 
the coverage criteria for facet injections The requested facet injections are not 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 Facet Joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Facet Joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the foot insert (L3000). 
 
You asked the Plan to pre-approve the foot insert. You say that you would like reconsideration because these 
inserts are medically necessary to help the member with her conditions. The Plan denied your request. The Plan 
says the clinical information provided does not show the shoe inserts are for shoes that are an integral part of a 
brace. 
 
The Plan must follow Medicare rules. Medicare rules say that inserts and other shoe modifications, L3000, are 
covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for 
the proper functioning of the brace. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the foot insert have not been met. Specifically, the record does not show that these inserts will be 
on a shoe that is an integral part of a covered brace. Therefore, we decided that the Plan does not have to pre-
approve the foot insert (L3000).
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 you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 the enrollee is currently undergoing treatment at an ACH for CoViD-19.  The 
enrollee is not intubated/ventilated. The enrollee does not require services at the LTACH that are not available 
at the acute care hospital where the enrollee is currently receiving care. There are no services available at the 
LTACH that the enrollee requires that are not available at the health care setting being offered by the health 
plan. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis. 
 
You asked the Plan to pre-approve Renflexis. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the use of this medication exceeds what is indicated by acceptable standards of 
medical practice and, therefore, this request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Renflexis. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found Renflexis is not FDA approved for the 
enrollee's diagnosis and the requested dosing regimen is not consistent with published dosing regimens. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Renflexis have not been met. Specifically, the dosing regimen exceeds 
published dosing regimens. Therefore, we decided that the Plan does not have to pre-approve Renflexis.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve skilled nursing facility services. The Plan denied your request. The Plan 
says you do not require skilled nursing or therapy services. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no 
identifiable daily skilled nursing or therapy needs. Our reviewer says that you do not meet the severity of 
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that 
the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Omnipod system. 
 
You asked the Plan to pre-approve the Omnipod system. You say that you really need the requested device 
because your blood sugar is hard to control. You say that you this is a life saving device. You say that the 
information from your doctor supports the need for the requested Omnipod system. The Plan denied your 
request. The Plan says the guidelines for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are covered for certain 
medical indications. 
 
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 Omnipod system. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found the documentation provided did 
not include an ABS or C-peptide showing that the enrollee has type 1 diabetes. There is no medical 
documentation showing the enrollee is on MDI and checking blood glucose levels 4 times a day. 
 
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 Omnipod system have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Omnipod system.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Omnipod Dash PDM. 
 
You asked the Plan to pre-approve Omnipod Dash PDM. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Omnipod Dash PDM. Our reviewer 
says that the requested item is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the enrollee is noted to have type II diabetes, which was diagnosed within the last two 
years. Until recently, the enrollee was taking a once daily long-acting insulin and a twice daily oral medication 
to treat her diabetes. During a recent hospitalization, a thrice daily short-acting insulin was added to her 
regimen. There is no documentation of how these changes are working or how the enrollee is complying with 
them. While it appears that the enrollee was to be referred to an endocrinologist, there is no documentation of 
this encounter. Other than the PA form, there is no indication of any plan to start the enrollee on an insulin 
pump, much less the requested Omnipod system. The documentation is insufficient to show that the requested 
device is medically necessary and 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 Omnipod Dash PDM have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Omnipod Dash PDM.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp 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 this drug is not being requested for a medically accepted indication. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical 
records provided, the enrollee has not tried and failed the required drug. There is no indication that the plan's 
required drug would likely be less effective and/or likely have adverse effects for the enrollee. In addition other 
causes of anemia (including B-12 deficiency, folate deficiency and iron deficiency, hemolysis and bleeding) 
have not been ruled out.

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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Aranesp for the enrollee.
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 you are stable and should be transferred. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the records show that 
you are currently in an acute care hospital (ACH) receiving treatment for COVID-19. There is no evidence that 
you require services that are not currently available at the ACH. As LTACHs and ACHs are licensed to provide 
the same level of care, there is no advantage in transferring you to the LTACH. The LTACH services are not 
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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 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 there is no trial and failure of zoledronic acid. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found Denosumab (Prolia) is 
indicated for postmenopausal osteoporosis at high risk for fracture. The Plan requires a trial of Zoledronic Acid 
before they will approve the requested drug. In this case, the patient has not tried and failed the required drug. 
There is no documentation provided indicating that the Plan's required drug would likely be less effective 
and/or likely have adverse effects for the enrollee. In this case, the enrollee has osteopenia and there is no  
history of osteoporotic fracture. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia for the enrollee.