Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that you would like to see a provider closer to your 
home. 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. The network provider is located 14.5 miles 
from your residence, which is an acceptable distance per Medicare rules. 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 provider.
Appeal type: Drugs
Decision: Unfavorable

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

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair. 
 
You asked the Plan to pre-approve power mobility device. You say that you cannot mobilize without a 
motorized wheelchair. The Plan denied your request. The Plan says the denial of payment for this device is 
correct, because the records do not show how your mobility limitation interferes with MRADLs, why a manual 
wheelchair does not meet your mobility needs, or that you can safely operate a power mobility device.  
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient?s condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power mobility device. Our reviewer 
says that you do not meet the Medicare criteria for the requested power mobility device. Our physician 
reviewer found based on the records provided there is no documentation that you have a personal mobility 
deficit that impairs participation in mobility-related activities of daily living (MRADLs) such as toileting, 
feeding, grooming, and bathing in customary locations within the home. There is no documentation that your 
mobility deficit cannot be helped by the use of a walker, cane, or manual wheelchair. The documentation does 
not show that you can safely operate a power mobility device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of power mobility device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 2 power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve these services. You say that the enrollee fell out of bed. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system and Group 4 power 
wheelchair (PWC) upgrade. 
 
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 covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system and Group 4 
PWCs are not covered. 
 
We looked at the file and Medicare rules. The requested power seat elevation system is denied by Medicare as 
not covered because it does not serve a purpose that is primarily medical in nature. The requested Group 4 
PWC upgrades are denied by Medicare as not covered because they exceed the needs for use inside of the 
home. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system and 
Group 4 power wheelchair (PWC) upgrade.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need to get strong enough to use a wheelchair 
and walker. The Plan denied your request. The Plan says you do not require three hours of rehab therapy a day. 
 
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 physician reviewer found 
that you were admitted to the acute hospital for a prolonged hospitalization with osteomyelitis of the right 
femur, requiring right hemipelvectomy, complicated by recurrent sepsis and respiratory failure. Your medical 
conditions are stable. The complexity of your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record 
documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain (D2740) for tooth # 4. 
 
You asked the Plan to pre-approve the dental service. You say that the enrollee needs a crown for tooth # 4. 
The Plan denied your request. The Plan says the porcelain crown is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
porcelain (D2740) for tooth # 4.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that you are unhappy with the network providers. 
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 provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard - soft appliance, full arch (D9945). 
 
You asked the Plan to pre-approve an occlusal guard. You say that the service is medically necessary. The Plan 
denied your request. The Plan says this service is not covered under your benefit package. 
 
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. Any service not listed in the 
EOC is not a covered benefit. 
 
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. Specifically, code D9945 is not listed as a covered benefit in the Plan's 
2020 EOC. Therefore, we decided that the Plan does not have to pre-approve an occlusal guard - soft appliance, 
full arch (D9945).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mandibular partial denture (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that the service you are requesting 
is medically necessary. The Plan denied your request. The Plan says this service exceeds the maximum count 
allowed per period. 
 
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 
mandibular partial denture when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. The file indicates that the service you are requesting was last 
provided and the benefit limit is exhausted for mandibular partial denture. Based on this 
information, we decided that the Plan's rules for coverage of the mandibular partial denture have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the mandibular partial denture (D5214).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex (J1561) 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 is 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 the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found there is no clear 
evidence of an immunoglobulin deficiency, abnormal WBC count, or other objective signs that the enrollee 
would benefit from Gamunex. Therefore, it will be considered not medically necessary for this patient at this 
time, based on the provided documentation. The provided notes did not clearly show evidence of the enrollee 
tolerating and having benefit from prior Gamunex to help support this request. Therefore, at this time, the 
provided documentation does not support that Gamunex is safe and effective for the patient, based on the 
provided documentation. 
 
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 Gamunex (J1561) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services you provided on August 6, 2020. 
Records show that you are an out of network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the assisted living facility where the member 
resides should have gotten authorization. The Plan denied your request. The Plan says unauthorized, non-plan 
care is not covered. 
 
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. 
 
You are not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. It is a 
provider's obligation to confirm that they have authorization from the Plan prior to rendering care. 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 you provided on August 6, 2020. Records show that you are an out of 
network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit. 
 
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 a lack of a compendia supported indication for this drug. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the records do not show 
an FDA approved indication for Retacrit, and use of Retacrit is not supported by the approved compendia for 
iron-deficiency anemia from blood loss. Therefore, Retacrit will be considered not medically necessary or 
reasonable. The documentation also does not support that Retacrit would be more safe and effective for you 
compared to standard of care for her clinical situation. 
 
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 Retacrit.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
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 Gel-One. Our reviewer says that the 
documentation does not support that the requested drug is medically reasonable or necessary. Our physician 
reviewer found that you have pain related to osteoarthritis of both knees, diagnosis confirmed with imaging 
studies. You have failed conservative treatment. The documentation does not support that you have tried and 
failed Orthovisc and Monovisc. The documentation does not support that there is an indication that the plan's 
required drugs would likely be less effective and/or likely have adverse effects. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Gel-One.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve an inpatient rehabilitation facility (IRF) admission. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan states that the services are not medically necessary; however, no 
medical records were provided for review. Without medical records, a determination based on medical 
necessity cannot be made. Therefore, we decided that the Plan has to pre-approve an inpatient rehabilitation 
facility (IRF) admission.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc-One. 
 
You asked the Plan to pre-approve Synvisc-One. You say that the requested drug is medically necessary. The 
Plan denied your request. The Plan says the requested drug requires step therapy. The Plan says that the step 
therapy requirements have not been met. The Plan also says that the requested drug is not medically necessary.  
 
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 Synvisc-One. Our reviewer says that 
the requested drug is not medically necessary. Our physician reviewer found the provided documentation does 
not show that the enrollee has trial and failed the required drugs Orthovisc or Monovisc. Therefore, the 
reviewer found that the criteria for coverage has not been met. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Synvisc-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing test services provided on August 6, 2020 by an 
out of network (OON) provider. 
 
You asked the Plan to pay for the hearing test services. You say that you needed your hearing aids adjusted and 
it had been at least a year since hearing tests were performed. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
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 had network providers 
available who could have provided 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 the hearing test services provided on August 6, 2020 by an out of network 
(OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RST Sanexas treatments. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there 
are no long-term studies that support this as an effective and safe treatment for neuropathy. 
 
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 requested services. Our physician 
reviewer found that the proposed therapy with the Sanexas device (electronic cell signaling therapy) has yet to 
be validated in any well designed clinical studies to date. Electronic cell signaling therapy is not a generally 
accepted form of therapy for any medical condition, given the lack of credible literature available on its use. 
This therapy is not consistent with the generally accepted standards of medical practice for management of 
neuropathic pain. There is sufficient peer reviewed literature available showing that the proposed therapy is 
safe and effective for the member's condition. In as much, the proposed therapy cannot be considered 
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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve RST Sanexas treatments.