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

 
We decided that the Plan does not have to pre-approve Botox 400 units (J0585). 
 
You asked the Plan to pre-approve Botox. You say that this service is medically necessary. The Plan denied 
your request. The Plan says the dosage requested exceeds the maximum allowed amount. 
 
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 Botox. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found the maximum total cumulative dose of Botox 
should not exceed 360 units over a three-month period from all sources, including injections in other sites of 
the body. A dose-ranging clinical trial investigated the efficacy of 50, 100, 150, 200, and 300 units of Botox 
and found durable efficacy for doses greater than 100 units and diminishing improvements in symptoms in 
doses greater than 150 units. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox 400 units (J0585).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown on tooth # 7 with dental code D2750. 
 
You asked the Plan to pre-approve a dental crown on tooth # 7 with dental code D2750. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you received a 
dental crown with dental code D2740 on tooth # 7 on August 31, 2020, therefore the 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental crown with dental 
code D2750 on tooth # 7 is not among those covered under this benefit in this case. The Plan contract clearly 
says that a crown with dental codes D2740, D2750, D2751, D2752, D2790, D2791, and D2792 are covered 
once per tooth per 60 months. The file shows that you received a dental crown with dental code D2740 on tooth 
# 7 on August 31, 2020, which is less than 60 months ago. Therefore, we decided that the Plan does not have to 
pre-approve a dental crown on tooth # 7 with dental code D2750.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio. 
 
You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says the drug is not being 
used for a medically accepted indication. 
 
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 Entyvio. Our physician reviewer found 
that the enrollee has a diagnosis of collagenous colitis. A review of approved compendia does not support the 
use of Entyvio for the provided diagnosis. 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 Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cologuard screening testing. 
 
You asked the Plan to pre-approve Cologuard. You say that you need this testing because of a positive fecal 
globin test result. The Plan denied your request. The Plan says the denial of authorization for this testing is 
correct, because you had a Cologuard test less than 3 years ago. 
 
The Plan must follow Medicare rules. Medicare rules say that Cologuard testing is covered once every three 
years for enrollees that meet the above criteria.  
 
We looked at the file and Medicare rules. Although the record does not show that you have received a 
Cologuard test within the past 3 years, you are not asymptomatic and therefore do not meet the criteria for 
Cologuard testing at this time. Based on this information, we decided that Medicare rules for coverage of 
Cologuard have not been met. Therefore, we decided that the Plan does not have to pre-approve Cologuard 
screening testing.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the lower 
extremity without contrast (73700). 
 
You asked the Plan to pre-approve this service. You say that a CT scan is medically necessary for the enrollee. 
The Plan denied your request. The Plan says a CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 this service. Our reviewer says that a 
CT scan is not medically necessary. Our physician reviewer found that the physical findings showed tenderness 
at the joint line and lateral to the patella, decreased range of motion, and a positive McMurray test. The 
enrollee had x-rays showing moderate arthritic changes only. She was treated with Celebrex and was ordered a 
CT scan of the knee. 
 
A magnetic resonance imaging (MRI) scan would typically be indicated as the enrollee had laxity with the 
McMurray's test and had pain; however, only after four to six weeks or conservative treatment such as physical 
therapy, weight loss, and nonsteroidal anti-inflammatory drugs for which there was no documentation of 
having been tried fully. Also, there was no explanation to getting a CT scan over an MRI as there was no 
contraindication to such. Therefore, this request for a CT scan will be considered not medically necessary at 
this time based on the documentation provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the lower extremity without contrast (73700).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated post and core for tooth 8. 
 
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. 
 
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 
prefabricated post and core for tooth 8.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Restasis 0.05% emulsion. 
 
You asked the Plan to pre-approve Restasis. You say that this service is medically necessary. The Plan denied 
your request. The Plan says this medication does not fall 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 Restasis 0.05% emulsion.  
 
Benefits for Restasis 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dentures. 
 
You asked the Plan to pre-approve the dentures. You say that these services are medically necessary. You also 
say that these services are needed due to the damage done to your teeth as a result of radiation therapy. The 
Plan denied your request. The Plan says Medicare covered services are limited to surgery of the jaw or related 
structures, setting fractures of the jaw or facial bones, or extraction of teeth to prepare the jaw for radiation 
treatments of neoplastic cancer disease. The Plan also says that there is no documentation to support the 
medical necessity of medical plan coverage of the cost of the dentures. 
 
Medicare generally does not cover dental services. The Plan follows the same rule.  
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction of erupted tooth (D7210). 
 
You asked the Plan to pre-approve the extraction of erupted tooth. You say that a regular dentist cannot 
perform the procedure. The Plan denied your request. The Plan says coverage is only provided for dental 
services when they are performed 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. The Plan covers the extraction 
of erupted tooth when the services are performed by a participating general dentist.  
 
We looked at the file and Medicare rules. The file indicates that the services will be performed by an oral 
surgeon and not a participating general dentist. Based on this information, we decided that the Plan's rules for 
coverage of the extraction of erupted tooth have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the extraction of erupted tooth (D7210).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional acupuncture treatments (97810) for the year 
2020. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says you have exhausted the acupuncture benefit for the 
year 2020. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and the Plans rules. Based on this information, we decided that the rules for coverage of 
acupuncture treatment have not been met. Specifically, your request exceeds the allowable six acupuncture 
treatments for the year 2020. Therefore, we decided that the Plan does not have to pre-approve additional 
acupuncture treatments (97810) for the year 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root-planing (UR) (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the service to be approved. 
You couldn't do services last year and now because of the pandemic. You also did not know the services are no 
longer covered by the plan. The Plan denied your request. The Plan says this service is not covered under the 
plan benefits. 
 
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. Services not listed is not 
covered by the plan. 
 
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 
periodontal scaling and root-planing (UR) (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nerve treatment on tooth 18. 
 
You asked the Plan to pre-approve nerve treatment on tooth 18. You say that you need the root canal to be able 
to chew. The Plan denied your request. The Plan says this procedure is not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or 
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve nerve treatment on 
tooth 18.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee out of network on 
July 28, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The 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 Plan 
did not pre-approve the item/service at issue. 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 physician services provided 
to the enrollee out of network on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transvenous phrenic nerve stimulation. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee has attempted and failed 
conventional treatment. The Plan denied your request. The Plan says the requested service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. There is currently insufficient evidence to show transvenous phrenic 
neurostimulation is reasonable and necessary for the treatment of illness. Based on this information, we decided 
that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve transvenous phrenic nerve stimulation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the external catheter (A9270). 
 
You asked the Plan to pre-approve the external catheter. You say that you would like reconsideration 
because this supply is necessary to help you sleep through the night The Plan denied your request. The Plan 
says the external catheter is a non-covered product. 
 
The Plan must follow Medicare rules. Medicare rules say that use of the appropriate HCPCS code assures that 
accurate processing can be accomplished resulting in a proper claim determination and reimbursement. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the external catheter have not been met. Specifically, the PDAC code assigned to the 
external catheter is a non-covered code per Medicare. Therefore, we decided that the Plan does not have to 
pre-approve the external catheter (A9270).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transport provided on July 24, 
2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you were taken to the 
hospital unnecessarily and misguided. The Plan denied your request. The Plan says the claim was processed 
accordingly with your 2020 EOC benefits. The Plan states they  received records from the provider, which 
includes an ambulance signature form, signed by you, which states that you understood that you would be 
financially responsible for the services, and would be responsible or any amount owed in addition to what your 
insurance pays. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
Review of the file show that you received ambulance transport on July 24, 2020. You were asked to pay a $200 
copayment for the ambulance transport. Your 2020 EOC states that enrollees must pay a $200 copayment for 
each Medicare-covered ground ambulance service. 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 copayment for 
ambulance transport provided on July 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pay for the medical services. You say that you are in excruciating pain and need to be 
seen as possible. The Plan denied your request. The Plan says this provider is out-of-network and there are in-
network providers that can render the services. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. 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 to be provided by an out-of-
network provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for radiation therapy for breast cancer - Image Guided Radiation Therapy 
for initial phase provided from August 17, 2020, through August 20, 2020. 
 
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your 
request. The Plan says that medical studies haven't proven that the use of the services are helpful for treatment 
of the member's health problem. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found as IMRT was approved for this patient (and not disputed) and it would be within accepted 
standards of medical practice to use IGRT with IMRT delivery due to the more conformal radiation delivery. 
Our physician reviewer found this appeal as favorable. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
radiation therapy for breast cancer - Image Guided Radiation Therapy for initial phase provided from August 
17, 2020, through August 20, 2020.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two abutment supported porcelain/ceramic crowns 
(D6058 x2) and occlusal guard (D9945). 
 
You asked the Plan to pre-approve the abutment supported crowns and occlusal guard. You say that you would 
like these services reprocessed for coverage. The Plan denied your request. The Plan says these services are not 
covered under the enrollee's 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. 
 
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 two 
abutment supported porcelain/ceramic crowns (D6058 x2) and occlusal guard (D9945).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on September 25, 
2020. 
 
You asked the Plan to waive the copayment for the CT scan. You say that insurance should cover the test. The 
Plan denied your request. The Plan says you were charged a copayment correctly. 
 
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 $275 
copayment for Outpatient Diagnostic test at Outpatient Hospital.  
 
You have been asked to pay a $108.13 copayment for the CT scan. The CT scan falls within the Outpatient 
Diagnostic test at Outpatient Hospital benefit category. The allowed amount for the test is $108.13 which is 
why your copayment is lower. 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 copayment for the CT scan provided on 
September 25, 2020.