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

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral 
periapical x-ray, and re-cement or re-bond of a fixed partial denture provided on May 21, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and 
re-cement or re-bond of a fixed partial denture. You say that you believe this should be covered because these 
services were urgently needed, and your plan provides coverage for urgently needed services. The Plan denied 
your request. The Plan says these services are 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 pay for the 
problem focused limited oral evaluation, first intraoral periapical x-ray, and re-cement or re-bond of a fixed 
partial denture provided on May 21, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional physical therapy. 
 
You asked the Plan to pay for the physical therapy. You say that you would like reconsideration because the 
additional physical therapy is medically necessary. The Plan denied your request. The Plan says the member 
can continue with a home exercise program without the guidance of a licensed therapist. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 pay for the physical therapy. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the specialized skill, knowledge and judgment of a qualified therapist 
is not required to establish, design and/or deliver a program to maintain the member's current condition or to 
prevent or slow further deterioration. 
 
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 physical therapy have not been met. Therefore, we decided that the Plan 
does not have to pay for additional physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cochlear implants for the enrollee. 
 
You asked the Plan to pre-approve the implants. You say that this is medically necessary. The Plan denied your 
request. The Plan says this does not meet the CMS criteria for unilateral hearing loss. 
 
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 implants. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee does not meet the criteria set by the NCD. The enrollee does not have bilateral moderate-to-
profound SNHL. She has normal to mild SNHL on the right. In addition, she has not tried a hearing aid for her 
left ear. Therefore she does not meet the criteria. 
 
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 implants have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cochlear implants for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 20, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
physician's 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 physician's services provided on July 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right shoulder arthroscopy with rotator cuff repair 
(29826, 29827, 29828). 
 
You asked the Plan to pre-approve this service. You say that a right shoulder arthroscopy with rotator cuff 
repair is medically necessary for the enrollee. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee presents with complaints of right shoulder pain with numbness down the arm. Clinical 
exam findings are reported to include limited shoulder range of motion, positive drop arm test, and external 
rotation weakness. There is imaging evidence of partial full thickness supraspinatus tear, biceps tenosynovitis, 
and moderate acromioclavicular osteoarthritis, without evidence of impingement. Detailed evidence of a recent, 
reasonable and/or comprehensive non-operative treatment protocol trial and failure has not been submitted. 
There is no clear evidence of physical therapy, home exercise program, or injections.  
 
Under consideration is a request for right shoulder surgery with subacromial decompression, rotator cuff repair 
and biceps tenodesis. Current evidence based medical literature would not support proceeding with surgery at 
this time, pending completion of a reasonable trial of conservative treatment. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request prior to 
conservative treatment. Therefore, this request for right shoulder surgery with subacromial decompression, 
rotator cuff repair and biceps tenodesis is not medically reasonable and 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 this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right shoulder arthroscopy with rotator cuff repair (29826, 29827, 29828).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 2, 2020. 
 
You asked the Plan to pay for the physician's 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 
physician's 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 physician's services provided on September 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services with dental code D5630 provided on 
August 21, 2020. 
 
You asked the Plan to pay for dental code D5630. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are 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, dental code D5630 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services with 
dental code D5630 provided on August 21, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an injection of regadenoson (a Medicare 
Part B drug), cardiovascular stress test, Single-Photon Emission Computed Tomography (SPECT) test, and 
technetium imaging contrast material provided on August 19, 2020. 
 
You asked the Plan to waive the cost-sharing for Part B drug, stress test, SPECT test, and imaging supplies. 
You say that based on the information provided in your book, your copayment should have been $100. The 
Plan denied your request. The Plan says the cost-sharing amounts you are being charged are 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 20% 
coinsurance for Part B drug, $25 copayment for stress test, $100 copayment for SPECT test, and 20% 
coinsurance for imaging supplies. A summary of your cost-sharing amounts is shown on the next page: 
  
Date of Service Service Provided 
Allowed 
Amount 
Cost-Share Per 
Contract 
Your Cost-Share 
Responsibility 
August 19, 2020 Part B Drug $237.48 20% coinsurance $47.50 
August 19, 2020 Stress Test $59.83 $25 copayment $25 
August 19, 2020 SPECT Test $443.62 $100 copayment $100 
August 19, 2020 Imaging Supplies $222.20 20% coinsurance $44.44 
Total    $216.94 
 
Your total cost-sharing responsibility is therefore $216.94. 
 
You have been asked to pay 20% coinsurance for Part B drug, $25 copayment for stress test, $100 copayment 
for SPECT test, and 20% coinsurance for imaging supplies. Part B drug, stress test, SPECT test, and imaging 
supplies fall within the "Medicare Part B Prescription Drugs" and "Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies" benefit categories. 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 cost-sharing for 
an injection of regadenoson (a Medicare Part B drug), cardiovascular stress test, Single-Photon Emission 
Computed Tomography (SPECT) test, and technetium imaging contrast material provided on August 19, 2020.
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 this is medically necessary. The Plan denied your 
request. The Plan says the enrollee's needs could be met at a lower level of care. 
 
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 surgical repair of a hip fracture after a fall. There are no medical needs requiring inpatient 
admission. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a 
need for physical and occupational therapy, it does not document a need for an intensive rehabilitation 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing, 
home with home health and home physical therapy, or home with outpatient therapy. 
 
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 enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010). 
 
You asked the Plan to pre-approve a mastectomy sleeve. You say that the mastectomy sleeve is medically 
necessary. The Plan denied your request. The Plan says this item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that mastectomy sleeves are not covered.  
 
We looked at the file and Medicare rules. The requested item is not covered by Medicare. Based on this 
information, we decided that Medicare rules for coverage of a mastectomy sleeve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a mastectomy sleeve (L8010).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Octreotide Acetate. 
 
You asked the Plan to pre-approve Octreotide Acetate. 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 a covered 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 Octreotide Acetate.  
 
We note that the plan has approved this drug under your Medicare Part D drug benefit.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve these services. 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 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has atrial fibrillation, low 
testosterone, benign prostatic hyperplasia, osteoporosis, pseudoarthrosis and failure of spine surgery. The 
Medicare-approved drug compendia do not support that Evenity is safe and effective for male patients. The 
services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Evenity.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee required stand-by assistance 
for walking to 150 feet with a walker. The enrollee was able to independently accomplish bed mobility. the 
enrollee required contact guard assistance for transfers and can climb 12 steps. The documentation does not 
support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse 
or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The 
documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As 
a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF 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 SNF admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve packaging (K0108) wheelchair component or accessory, 
not otherwise specified (K0108). 
 
You asked the Plan to pre-approve the wheelchair accessories. You say that please reconsider the original 
decision to deny the equipment as it is truly medically necessary for the enrollee. The Plan denied your request. 
The Plan says the requested service 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 the wheelchair accessories. Our 
reviewer says that  Our physician reviewer found  
 
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 wheelchair accessories have not been met. Therefore, we decided that the 
Plan does not have to pre-approve packaging (K0108) wheelchair component or accessory, not otherwise 
specified (K0108).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Paclitaxel protein bound injection (J9264) and 
Bevacizumab-awwb (Q5107). 
 
You asked the Plan to pre-approve Paclitaxel and Bevacizumab. You say that adding MVASI to Abraxane 
increases the response rate. You also say that it is medically necessary that the enrollee receive the 
combination. The Plan denied your request. The Plan says these drugs are not supported for the enrollee's type 
of cancer. 
 
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 Paclitaxel and Bevacizumab. Our 
reviewer says that these drugs are not medically reasonable and necessary for the enrollee. Our physician 
reviewer found the requested use of this combination is not Food and Drug Administration (FDA) approved. 
Our reviewer found that the requested use of the combination is not supported in any of the CMS approved 
compendia. Our physician reviewer also found that the requested use is not listed as not indicated, not 
recommended, or not supported in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Paclitaxel and Bevacizumab have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Paclitaxel protein bound injection (J9264) and Bevacizumab-awwb (Q5107).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with codes A6549 & 
E1399. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings are medically 
necessary. The Plan denied your request. The Plan says this type of compression stocking is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by codes A6549 & 
E1399 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 codes A6549 & E1399.