Persius/hicric huggingface dataset:
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). 
 
You asked the Plan to pre-approve the core buildup. You say that you need this core buildup, but it was denied. 
The Plan denied your request. The Plan says core buildup 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. 
 
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 
core buildup, including any pins when required (D2950).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Enbrel SureClick. 
 
You asked the Plan to pre-approve the Enbrel SureClick. You say that you would like reconsideration because 
this drug is medically necessary. The Plan denied your request. The Plan says this drug is not covered for the 
members' condition under 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 Enbrel SureClick.  
 
Benefits for the Enbrel SureClick 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 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 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 considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee does need physical and occupational therapy, the rehabilitation needs are not complex and do not 
require an intensive rehabilitation program. There is not a reasonable expectation that this 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: 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 the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation
provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is
not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular
physician evaluation. The enrollee's care needs can be met at a lower level of care.
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: 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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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 considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The 
medical record supports a need for physical and occupational therapy but does not support the need for an 
intensive rehabilitation program. Services could be provided in a different level of care. There is not a 
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare 
criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services (D5212). 
 
You asked the Plan to pre-approve dental services (D5212). You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says lower dentures with dental code D5212 is not covered 
by Medicare or the Plan's supplemental 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 
dental services (D5212).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee needs this for rheumatoid arthritis. 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 Methotrexate 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: 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 LTACH Admission is medically necessary. The Plan denied your request. The Plan says you can receive same services at the current level of care.
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 documentation does not support you require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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: 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the enrollee is with a past 
medical history of hypertension, hypothyroidism, previous stroke and unstable gait who presented to the acute 
hospital on 08/07/2020 with abdominal pain, nausea, vomiting, and diarrhea. She was treated in the hospital 
with intravenous antibiotics and surgical consultation. The enrollee underwent surgery on 08/13/2020 for 
diverticulitis with abscess. Her post-operative course was complicated by acute kidney injury and pneumonia. 
She is weak and deconditioned and is working with physical and occupational therapy. She is walking 5 feet 
with a rolling walker with moderate assistance and is minimum to moderate assist for transfers and activities of 
daily living (dependent for toileting). Therapy is reported to be limited due to poor endurance. She is still 
recovering from pre-renal azotemia and is receiving intravenous fluids. 
 
Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation 
needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The enrollee does require physical therapy and occupational therapy services but based on the medical records 
provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the 
medical records provided there is concern that the enrollee will not be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an inpatient rehabilitation 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 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 Pramipexole ER for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that this is needed for the treatment of the enrollee's 
Parkinson's disease. 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 Pramipexole ER 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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that the requested additional 
transportation is necessary. The Plan denied your request. The Plan says the requested additional transportation 
trips exceed the benefit limit. Therefore, coverage criteria has not been met. 
 
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 one-way transportation 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 (A0120).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Botox injections for craniofacial sweating.
You asked the Plan to pre-approve the Botox injections. You say that this is medically necessary. The Plan denied your request. The Plan says that this treatment is only approved for use for axillary hyperhidrosis.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Botox injections. Our reviewer says that the requested treatment is considered medically reasonable and necessary. Our physician reviewer found Botox can be used to treat craniofacial hyperhidrosis when the first-line medications are either ineffective or contraindicated, as 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 the Botox injections have been met. Therefore, we decided that the Plan has to pre-approve Botox injections for craniofacial sweating.
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve acupuncture services. You say that you did not have luck with an in-
network provider; therefore, you would like to see an out-of-network provider. The Plan denied your request. 
The Plan says there are in-network providers available for these 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 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 
acupuncture services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided by a 
participating provider on July 26, 2019 to August 23, 2019. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should only have a 
$5-$10 copayment. The Plan denied your request. The Plan says the correct copayments have 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 $225 
copayment for colorectal cancer screening/diagnostic colonoscopy.  
 
You have been asked to pay less than a $225 copayment for a diagnostic colonoscopy. You have been asked to 
pay a total of $100 ($50 + $50 = $100). A diagnostic colonoscopy falls within the colorectal cancer 
screening/diagnostic colonoscopy 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 copayment for a 
diagnostic colonoscopy provided by a participating provider on July 26, 2019 to August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested proton beam 
radiation therapy is medically necessary. The Plan denied your request. The Plan says the requested proton 
beam radiation therapy 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 pre-approve proton beam radiation therapy. Our 
reviewer says that the requested proton beam radiation therapy is not medically necessary. Our physician 
reviewer found there is nothing in the case file that credibly suggests that other radiation techniques would be 
unacceptable and/or that proton therapy would yield a clinically meaningful advantage for this enrollee. The 
most recent version of the NCCN guidelines (v5.2020) do not address proton therapy for breast cancer (as they 
do for some other sites such as prostate cancer, head and neck cancer and lung cancer). In the recently released 
ASTRO model policy for proton therapy breast cancer is not listed in the Group 1 (disease sites that frequently 
support proton therapy) though is listed within Group 2 (sites that are suitable for Coverage with Evidence 
Development categories). 
 
In this case, there is inadequate documentation of need to be considered to be furnished in accordance with 
accepted standards of care. The case file does not provide a plausible rationale that would meet ASTRO criteria 
by showing a reduction in normal tissue exposure. A dosimetric rationale was not provided in this case, in 
which an insufficient 3D or IMRT plan justified the need for proton 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 proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested consultation. 
 
You asked the Plan to pre-approve the consultation. The Plan denied your request. The Plan says out-of-
network providers are available only when your medical group does not have the appropriate expertise in their 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the 
requested consultation.
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 the enrollee is not following commands. His 
needs appear to be custodial 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.