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

 
We decided that the Plan does not have to pre-approve Gocovri. 
 
You asked the Plan to pre-approve Gocovri. You say that the enrollee's tremors remain unchanged. The Plan 
denied your request. The Plan says this drug is not covered for the enrollee's condition by the Part B plan. 
 
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 Gocovri.  
 
Benefits for Gocovri 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: 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 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 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 medically necessary. Our physician reviewer found the enrollee was admitted for 
congestive heart failure. He is currently medically stable. He has no complex nursing or rehabilitation needs. 
He 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 the enrollee 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the enrollee does not 
have a history of osteoporosis-related fracture; or have failed, or have a contraindication to Zoledronic acid. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our physician reviewer found 
that the enrollee has a diagnosis of age-related osteoporosis without pathological fracture. The Plan requires a 
history of osteoporosis-related fracture; have failed, or have a contraindication to Zoledronic acid before they 
will approve the requested drug. She does not have a prior history of fracture. The notes do not show a trial and 
failure of Zoledronic acid. Zoledronic acid should be equally effective for this enrollee. There was no provided 
evidence that would suggest Prolia would cause less side effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate. 
 
You asked the Plan to pre-approve Methotrexate. The Plan denied your request. The Plan says the requested 
medicine 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 Methotrexate.  
 
Benefits for Methotrexate 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy 
services on a daily basis. You do not meet 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the provisional splinting (D4321) and the tooth splinting and 
stabilization (D7270 x 2) provided on July 7, 2020. 
 
You asked the Plan to pay for the dental services. You say that you fell and broke 2 teeth. You say that you 
were in the hospital for 2 days. You say that you went to see an oral surgeon. You also say that you do not 
understand why the necessary dental surgery was not covered. You say that The Plan denied your request. The 
Plan says the services you received are dental in nature. The Plan says the services you received are related to 
splinting teeth, including multiple abutments, or any service to stabilize periodontally weakened teeth. The Plan 
also says that these services and services related to them 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 
provisional splinting (D4321) and the tooth splinting and stabilization (D7270 x 2) provided on July 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve drugs dispensed in the office for home use. 
 
You asked the Plan to pre-approve the requested services. You say that you are in pain. The Plan denied your 
request. The Plan says the service is not a covered 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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve drugs 
dispensed in the office for home use.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the panoramic X-ray (D0330), the 
bitewings - four radiographic images (D0274), the comprehensive oral evaluation (D0150) and cleaning 
services (D1110) provided on August 7, 2020 from an out-of-network (OON) provider. 
 
You asked the Plan to provide reimbursement for the panoramic X-ray, bitewing X-ray, comprehensive oral 
evaluation, and cleaning services. You say that you were not aware this provider was OON and would like this 
claim reprocessed and approved for payment. The Plan denied your request. The Plan says the claims 
processed correctly and no reimbursement is due. 
 
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. 
 
We looked at the file, and Medicare rules. Although the Plan has supplemental coverage, panoramic X-rays are 
never covered and comprehensive oral evaluations are only covered once every 3 years. Furthermore, the Plan 
correctly charged you the 50% coinsurance for bitewing X-rays and cleaning services received from an OON 
provider. You are responsible for the difference between the average negotiated in-network fee schedule and 
the charged fees when services are received OON.  
 
 
 
 
 
 
Based on this information, we decided that the Plan's rules for coverage of the panoramic X-ray, bitewing X-
ray, comprehensive oral evaluation, and cleaning services have not been met. Therefore, we decided that the 
Plan does not have to provide reimbursement for the panoramic X-ray (D0330), the bitewings - four 
radiographic images (D0274), the comprehensive oral evaluation (D0150) and cleaning services (D1110) 
provided on August 7, 2020 from an out-of-network (OON) provider.
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 the enrollee's condition requires management by a 
physician who specializes in rehab. The Plan denied your request. The Plan says the enrollee does not require 
an intensive, complex, multidisciplinary approach to daily 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 physician reviewer found 
that the enrollee was admitted to the acute hospital for COVID-19 pneumonia. His medical conditions are 
stable. The complexity of the enrollees 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The 
Plan denied your request. The Plan says the requested Keytruda is not medically necessary. 
 
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 Keytruda. Our reviewer says that the 
requested Keytruda is not medically necessary. Our physician reviewer found the enrollee is diagnosed with 
ovarian cancer. Keytruda is not FDA approved for maintenance therapy. Keytruda is not supported by one of 
the major compendia or by clinical research that appears in a CMS-approved medical journal without MSI-
high/MMR or TMB greater than 10. Keytruda is not medically necessary in this case. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the lower tissue conditioning (D5821), the upper 
tissue conditioning (D5850), and the interim lower partial denture (D5821) provided on August 10, 2020. 
 
You asked the Plan to reimburse you for the dental services. You say that a plan representative advised that up 
to $500 would be paid for dental services. You say that you understand that the provider would not file a claim. 
You also say that you could file the claim because you did not opt out of Medicare. The Plan denied your 
request. The Plan says the provider in this case has opted out of Medicare. The Plan says that payment cannot 
be made for services that you receive from a provider who has opted out Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the lower tissue conditioning (D5821), the upper tissue conditioning (D5850), and the interim lower partial 
denture (D5821) provided on August 10, 2020.  
 
 
 
 
 
 
 
Your complaint about being misinformed by a plan representative is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit (99214) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve an office visit 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 these services. 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 
an office visit (99214) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper partial dentures. 
 
You asked the Plan to pre-approve the requested dentures. The Plan denied your request. The Plan says your 
benefit has been exhausted. 
 
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.  
 
We looked at the file, and Medicare rules. The records show that you received dentures on February 7, 2020. 
Your plan only covers dentures once every 5 years. Based on this information, we decided that the Plan's rules 
for coverage of the requested dentures have not been met. Therefore, we decided that the Plan does not have to 
pre-approve upper partial dentures.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided on June 26, 2020 
through July 1, 2020. 
 
You asked the Plan to pay for SNF care provided on June 26, 2020, through July 1, 2020. You say that the 
services rendered were medically necessary. The Plan denied your request. The Plan says the member had no 
skilled therapy or skilled nursing service needs. 
 
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 pay for SNF care. Our reviewer says that daily 
skilled services were not necessary. Our physician reviewer found the beneficiary did not require skilled 
nursing or therapy services on a daily basis and there were no identifiable skilled therapy service needs.   
 
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 care have not been met. Therefore, we decided that the Plan does not have 
to pay for skilled nursing facility (SNF) care provided on June 26, 2020 through July 1, 2020.
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 the enrollee's condition is critical. The Plan denied 
your request. The Plan says it is not reasonable to expect the enrollee will be able to actively participate in the 
intensity of services of an IRF. 
 
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 the enrollee was admitted to the acute hospital for surgical repair of a hip fracture after a fall. Her medical 
conditions are stable. The complexity of her nursing, medical and rehabilitation needs does not require an acute 
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable 
expectation that she will be able to fully participate in and benefit from the intensive rehabilitation therapy 
program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diabetic shoes and inserts provided on May 22, 2020. 
 
You asked the Plan to pay for the diabetic shoes and inserts. You say that you did not know your doctor needed 
to call for authorization. The Plan denied your request. The Plan says you did not have prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that prior authorization is required for therapeutic custom-molded shoes and inserts. 
 
The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for 
these items. Therefore, we decided that the Plan does not have to pay for the diabetic shoes and inserts 
provided on May 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services requested are medically 
necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be gradually improving but requires additional short term 
acute care services to further improve which can be safely be completed in the current setting. The patient does 
not require services at the LTACH that are not already available at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that the facility has the most advanced technology 
for the treatment of your diagnosis. The Plan denied your request. The Plan says your network has providers 
who can manage your care. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
medical services to be provided by an out of network (OON) provider.