Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy (77525). 
 
You asked the Plan to pre-approve proton beam therapy. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 
not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that proton therapy for prostate cancer is not experimental, and in fact is an accepted 
treatment approach however, any potential benefit or detriment of proton therapy over standard intensity-
modulated radiation therapy (IMRT) for routine cases is investigational. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (77525).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve the SNF services. You say that the records provided support that the SNF 
level of care is medically necessary. The Plan denied your request. The Plan says the level of care provided in a 
SNF 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 the SNF services. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and 
inhaled medications, had stable vital signs, and tolerated a regular diet. The enrollee had uncomplicated wound 
care to a biopsy site on his nose and topical Calmoseptine applied to his buttocks. The enrollee was dependent 
on functional mobility and required varying assist with activities of daily living. The enrollee used a powered 
wheelchair as baseline. There are no identifiable skilled nursing service needs. There are no identifiable skilled 
therapy service needs. The enrollee does 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 the SNF services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve porcelain crowns (D2740 x 3), the gingival irrigation 
(D4921 x 4), an occlusal guard (D9944), and an occlusal guard adjustment (D9943). 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says porcelain crowns are not listed as a covered service. The Plan says 
gingival irrigation is not listed as a covered service. The Plan says the occlusal guard is not listed as a covered 
dental item. The Plan also says that the occlusal guard adjustment 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 
porcelain crowns (D2740 x 3), the gingival irrigation (D4921 x 4), an occlusal guard (D9944), and an occlusal 
guard adjustment (D9943).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you feel that this item will be a big help 
to your current situation. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of an interspinous spacer (C1821, 22869). 
 
You asked the Plan to pre-approve the spacer placement. You say that the service is medically necessary. The 
Plan denied your request. The Plan says rules for coverage 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 the spacer placement. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested spacer device remains experimental. More research is needed to show 
safety and efficacy. 
 
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 spacer placement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the placement of an interspinous spacer (C1821, 22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5257) purchased on March 10, 2020. 
 
You asked the Plan to pay for hearing aids. You say that there are no providers within 50 miles of 
the enrollee's address. The Plan denied your request. The Plan says rules for payment have not been met. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when obtained from a specific provider.
 
We looked at the case file and the Plan's rules there are 4 providers within 30 miles of the 
enrollees address. Based on this information, we decided that the Plan's rules for coverage of hearing aids have 
not been met. Therefore, we decided that the Plan does not have to pay for hearing aids (V5257) purchased on 
March 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital inpatient care services (99222) provided June 
12, 2019. 
 
You asked the Plan to pay for the inpatient services. You say that you depend on the facility for timely 
notification of patient's health insurance coverage. Please reconsider processing the claim for services rendered. 
The Plan denied your request. The Plan says the claim was submitted past the timely filing limit. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the inpatient services was not filed until July 20, 2020. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for initial hospital inpatient care services (99222) provided June 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a raised toilet seat. 
 
You asked the Plan to pre-approve a raised toilet seat. You say that you would like reconsideration because the 
member's conditions make it difficult for them to use the toilet. The Plan denied your request. The Plan says 
this is a non-covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature.  
 
While a raised toilet seat may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that the enrollee needs the partial dentures. 
The Plan denied your request. The Plan says partial dentures are covered once every 60 months. The Plan also 
says that the frequency limit for partial dentures has been reached. 
 
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 frequency limit of once every 60 
months has been reached. The record shows that the Plan paid for partial dentures that you received on January 
2, 2017. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and 
a partial lower denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee resides in a SNF and Medicare 
does not cover durable medical equipment outside the use of the enrollee's home. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that a power wheelchair and accessories is being requested for use in a SNF or hospital. 
Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the enrollee has been successful on this medication. 
The Plan denied your request. The Plan says this is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second opinion consultation (99205) to be provided by 
an out of network (OON) provider. 
 
You asked the Plan to pre-approve a second opinion consultation to be provided by an OON provider. You say 
that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that 
are able to provide this service. Therefore, coverage criteria has not been met. 
 
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 second opinion consultation (99205) 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 Dexcom G6 continuous glucose monitor. 
 
You asked the Plan to pre-approve continuous glucose monitor. You say that you have tried another monitor 
but it did not work for you. The Plan denied your request. The Plan says the denial of authorization for this 
device is correct, because you do not use insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least 
three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous 
glucose monitor.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for medical supplies provided by a 
participating provider on June 2, 2020. 
 
You asked the Plan to waive the coinsurance for medical supplies. You say that you were told that you would 
not be charged for this. The Plan denied your request. The Plan says the correct coinsurance has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for durable medical equipment and related supplies.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for medical supplies. The total allowed 
amount is $52.23. The total amount you are being asked to pay is $10.45 ($52.23 x 20% = $10.45). Medical 
supplies fall within the durable medical equipment and related supplies benefit category. 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 coinsurance for medical supplies provided by a participating provider on June 2, 
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Simponi Aria. 
 
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 self-administered drugs are 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 Simponi Aria.  
 
Benefits for these services 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 Nivolumab (Opdivo). 
 
You asked the Plan to pre-approve Opdivo. The Plan denied your request. The Plan says the off-label use of the 
medication is not supported. 
 
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 Opdivo. Our physician reviewer found 
that Opdivo has been requested to treat metastatic colon cancer with microsatellite stable and high tumor 
mutational burden disease who has had previous treatments. Opdivo is not FDA approved for the requested 
use. Opdivo is not supported in any of the CMS approved compendia for this use. The use is not listed as not 
indicated, not supported or not recommended in any of the compendia. The documentation does not support 
that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Nivolumab (Opdivo).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the endodontic therapy (D3320) for tooth # 12. 
 
You asked the Plan to pre-approve the dental service. You say that the endodontic therapy is medically 
necessary due to the enrollee's comorbidities. The Plan denied your request. The Plan says endodontic services 
are not covered under your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
endodontic therapy (D3320) for tooth # 12.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory testing provided on July 10, 2020. 
 
You asked the Plan to pay for the laboratory testing. The Plan denied your request. The Plan says with limited 
exceptions, while you are a member of our plan you must use network providers to get your medical care and 
services. The only exceptions are emergencies, urgently needed services when the network is not available 
(generally, when you are out of the area), out-of-area dialysis services, and cases in which the Plan authorizes 
use of out-of-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 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 
laboratory 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 laboratory testing provided on July 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy (63047). 
 
You asked the Plan to pre-approve laminectomy, facetectomy and foraminotomy. You say that this is medically 
necessary. The Plan denied your request. The Plan says you have not tried sufficient conservative 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 laminectomy, facetectomy and 
foraminotomy. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found not enough conservative measures have been tried and 
failed. More physical therapy is needed before surgery can 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 laminectomy, facetectomy and foraminotomy have not been met. Therefore, we 
decided that the Plan does not have to pre-approve laminectomy, facetectomy and foraminotomy (63047).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter mitral valve replacement (0483T). 
 
You asked the Plan to pre-approve transcatheter mitral valve replacement. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve transcatheter mitral valve replacement. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found transcatheter mitral valve-in-valve replacement has not been 
adequately studied and long-term outcomes have not been validated compared to surgical mitral valve 
replacement. Coverage criteria for transcatheter mitral valve replacement are not met since it should be 
considered investigational in enrollees who do not have prohibitive surgical risk. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcatheter mitral valve replacement have not been met. Therefore, we 
decided that the Plan does not have to pre-approve transcatheter mitral valve replacement (0483T).