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

 
We decided that the Plan does not have to pre-approve levothyroxine 150mcg tablets. 
 
You asked the Plan to pre-approve the levothyroxine tablets. You say that this medication is necessary. The 
Plan denied your request. The Plan says this is an oral drug and cannot be covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve levothyroxine 150mcg 
tablets.  
 
Benefits for the levothyroxine tablets may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zolmitriptan, 5mg tablets. 
 
You asked the Plan to pre-approve Zolmitriptan. You say that Zolmitriptan is medically necessary. The Plan 
denied your request. The Plan says this drug is not eligible for coverage under the Part B medical 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 Zolmitriptan, 5mg tablets.  
 
Benefits for Zolmitriptan may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entresto. 
 
You asked the Plan to pre-approve this drug. You say that you have chronic combined systolic and diastolic 
heart failure. The Plan denied your request. The Plan says that this is not covered 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 Entresto.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Synvisc injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that Orthovisc and Monovisc are not carried in the 
office. The Plan denied your request. The Plan says the plan has chosen to implement step therapy rules for 
viscosupplement agents, such as Synvisc. 
 
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 injection. Our reviewer says that the 
requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, 
requires these be trialed first. The provider stated that the preferred agents are not carried in his office.  The 
Plan allowed for "the use of one of the preferred agents."  The documentation does not outline 
contraindications or reasons either of these medications were not considered. Without the support of the 
documentation, Synvisc is not approved as step criteria is not 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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Synvisc injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you would like reconsideration 
because the member's clinical data supports this therapy as an effective long term therapy for chronic back and 
leg pain. The Plan denied your request. The Plan says there is no network deficiency and this is not an 
emergent procedure. 
 
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 
the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve RadiationTherapy for Prostate Adenocarcinoma. 
 
You asked the Plan to pre-approve the RadiationTherapy for Prostate Adenocarcinoma. You say that you 
would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan 
says the type of treatment requested is not known to be more effective than other types of radiation therapy. 
 
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 RadiationTherapy for Prostate 
Adenocarcinoma. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found the preferred radiation therapy choices are 
brachytherapy and External Beam Radiation Therapy. Proton Beam Therapy is not compendia approved. 
 
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 RadiationTherapy for Prostate Adenocarcinoma have not been met. 
Therefore, we decided that the Plan does not have to pre-approve RadiationTherapy for Prostate 
Adenocarcinoma.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Toujeo Solostar for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that this is self-administered and not covered. 
 
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 Toujeo Solostar for the 
enrollee.  
 
Benefits for this drug 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the physical therapy services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the out of network physical therapy services. You say that you are located 
onsite at the enrollee's assisted living facility. You say that this will assist the enrollee in avoiding unnecessary 
travel and exposure to COVID-19. The Plan denied your request. The Plan says medically necessary care is 
available in network. 
 
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 
the physical therapy services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99204) to be rendered by the out of 
network (OON) provider. 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says an in-network provider is available to provide the 
requested service. 
 
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 service at issue in this appeal. We found no exception that would require the 
Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office 
visit (99204) to be rendered by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional trips. You say that you need to get to your treatment 
appointments. The Plan denied your request. The Plan says the benefit limit has been reached. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #32. 
 
You asked the Plan to pre-approve the crown. You say that your teeth are vital to your health, and how you 
look is important. You also say that your indigestion is related to your inability to chew food well enough. The 
Plan denied your request. The Plan says there is not enough bone around the tooth for it to be successful for 
treatment. The tooth must have 50% bone support to approve this service, and tooth #32 does not have at least 
50% bone support. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the crown 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that the 
criteria for coverage for a crown (D2740) for tooth #32 has not been met. Our physician reviewer found there is 
a poor periodontal prognosis for the retention of tooth #32 due to the poor bone support and furcation 
involvement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2740) for tooth #32.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard.
You asked the Plan to pre-approve the occlusal guard. The Plan denied your request. The Plan says this service is not a covered benefit under your policy.
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 an occlusal guard.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the stationary bike and elliptical. 
 
You asked the Plan to pre-approve the stationary bike and elliptical. You say that you have been going to the 
gym for almost 20 years, are both 71 and are at high risk for COVID19. You could put both machines in your 
garage so you could exercise safely. The Plan denied your request. The Plan says exercise equipment is not 
covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve the stationary bike and elliptical.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the upper 
extremity (73221). 
 
You asked the Plan to pre-approve the MRI. You say that the MRI 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 MRIs are covered only when they are medically 
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 MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found there has been no documented right side x-ray 
imaging study to evaluate new symptoms, and no documented 6-week trial of provider directed conservative 
management. Records do not support the MRI of the right shoulder at this time. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Magnetic Resonance Imaging (MRI) of the upper extremity (73221).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the lumbar spine for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says the test was not approved, as the enrollee is not shown to have met the necessary 
criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no 
documentation of an adequate trial and failure of physical 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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the lumbar spine for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction provided by an oral surgeon.
You asked the Plan to pre-approve the extraction. You say that you need your tooth extracted. You say that you
were informed you needed to see an oral surgeon. The Plan denied your request. The Plan says dental services
are only covered when rendered by a participating general dentist.
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, services provided by a non-general
dentist are not among those covered under this benefit. Therefore, we decided that the Plan does not have to
pre-approve the extraction provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide inpatient hospital care following a knee arthroplasty, for the
enrollee.
You asked the Plan to provide inpatient hospital care. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay 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 provide inpatient hospital care. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating inpatient level of care for a knee
arthroplasty. The enrollee will not need any inpatient diagnostic studies or therapeutic interventions. The
review has determined that the medical records provided did not meet the requirements for an inpatient stay
following a knee arthroplasty (27447).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan
does not have to provide inpatient hospital care following a knee arthroplasty, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve chiropractic services. You say that you would like approval for these 
services. You say that these services will help your condition. The Plan denied your request. The Plan says the 
services can be provided by an in-network dermatologist. The Plan says that there are in-network providers 
available. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 
chiropractic services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reusable oral thermometer (A4931). 
 
You asked the Plan to pre-approve the Oral thermometer. You say that you need to monitor your temperature 
and is unable to afford to buy a new one. The Plan denied your request. The Plan says this item is not covered 
under Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a reusable oral thermometer (A4931).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99204 x 2) to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit (99204 x 2) to be rendered by the out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950) and a crown (D2751). 
 
You asked the Plan to pre-approve the core buildup and crown. The Plan denied your request. The Plan says 
core buildup is not a covered service. The Plan also says that crowns have a benefit limit to two per calendar 
year, and the enrollee gone over this limit. 
 
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, core buildup (D2950) is not among 
those covered under this benefit. The contract also clearly states that crowns are limited to 2 per 1 calendar 
year. The record shows that the enrollee received 3 crowns (D2751 x3) on March 3, 2020, two of which were 
covered by the Plan, and the enrollee's crowns benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve a core buildup, including any pins when required (D2950) and a crown (D2751).