Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance provided on March 17, 2020. 
 
You asked the Plan to pay for periodontal maintenance. You say that two cleanings are paid for per year. You 
say that 50% should be paid. 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. 
 
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 
periodontal maintenance provided on March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scaling and root planing on February 
26, 2020. 
 
You asked the Plan to pay more for the scaling and planing and gingival irrigation. You say that you called the 
Plan and were advised that you still had money left on your account. The Plan denied your request. The Plan 
says your calendar year maximum has been met. The Plan also says that you are responsible for the denied 
amount of $315.00. 
 
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 Plan offers a $1,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the any amount over and above the allowance amount. The record shows that you met the 
annual maximum benefit while processing this claim for the February 26, 2020 date of service, and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the 
periodontal scaling and root planing on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT 99100) provided on March 18, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not 
separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee 
Schedule indicates that payment for covered services are always bundled into payment for other services not 
specified.  
 
We looked at the file and Medicare rules. Procedure code 99100 is assigned a status indicator of ?B? under the 
Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into 
payment for other services. No separate payment can be made for the anesthesia services (99100). Based on 
this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we 
decided that the Plan does not have to pay for the services (CPT 99100) provided on March 18, 2020.
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. It is not clear that you would be able to fully benefit and/or participate in an IRF 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Farxiga tablets. 
 
You asked the Plan to pre-approve the Farxiga tablets. You say that the enrollee would benefit from the glucose 
reduction and the cardiovascular protection that a medication like Farxiga can provide. The Plan denied your 
request. The Plan says this drug is not covered for the enrollee's condition by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Farxiga tablets.  
 
Benefits for the Farxiga tablets may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation services to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve out of network consultation services. You say that the enrollee cannot stand 
for more than 30 minutes and you believe it is due to autonomic dysfunction. You say that there are no 
specialists in the network that provide the services needed. You say that the enrollee once had clogged arteries 
that was not recognized by the network providers, and resulted in his suffering a heart attack. The Plan denied 
your request. The Plan says the enrollee can be seen within the primary 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 consultation services. There are multiple providers within the network who are able 
to provide consultation and second opinion services for treatment of the enrollee. We found no exception that 
would require the Plan to pre-approve out of network services. Therefore, we decided that the Plan does not 
have to pre-approve consultation services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
You asked the Plan to provide additional reimbursement for Spironolactone 25 mg purchased April 15, 
2020 at your pharmacy. The Plan did not grant this request. We received this case to conduct an 
independent review.  
 
  
Medicare rules allow a Part D Plan to apply coinsurance and copayments to covered drugs. If you pay the 
full cost of a prescription drug out-of-pocket or if you find you have paid more than you expected to pay 
under the Plan's coverage rules, you can ask the Plan to pay you back. When submitting a request for 
reimbursement, the Plan requires that you submit your receipt documenting the payment you have made 
along with your reimbursement request. In this case, you submitted a paid receipt for Spironolactone 25 mg 
purchased April 15, 2020 at your pharmacy. The Plan provided reimbursement for this fill and applied it 
towards your deductible but stated that you were responsible for the difference between the cash price paid 
and the Plan's negotiated contract rate for the drug because the pharmacy did not automatically submit your 
claims online to be processed by the Plan. The Plan stated that the pharmacy is a network pharmacy. The 
record indicates that you purchased Spironolactone 25 mg out of pocket and without your prescript drug ID 
card. The policy for an enrollee to be responsible for the difference between the cash price paid and the 
Plan's contracted negotiated rate for a drug for purchases made at in-network pharmacies that are not 
automatically run through the Plan's online claims processing system is limited to those situations in which 
online claims processing is available at the time of purchase but is not utilized. Since you submitted a 
receipt showing full price for this prescription, it appears that this is a situation in which the Plan's policy 
of charging the enrollee the difference between the cash price paid and the Plan's contracted negotiated rate 
for the drug is applicable. Therefore, it is our decision that the Plan is not required to provide additional 
reimbursement for Spironolactone 25 mg purchased April 15, 2020 at you pharmacy.
Appeal type: Lab
Decision: Unfavorable

 
You asked the Plan to cover Estring. The Plan did not grant this request. We received this case to conduct 
an independent review.  
 
We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request 
for Estring 2mg vaginal ring. The drug is requested to treat postmenopausal atrophic vaginitis. You sent a 
letter dated August 12, 2020 clarifying the diagnosis and medical history. You state that the enrollee has 
tried and failed Estrace vaginal cream. Estring 2 mg vaginal ring is not on the Plan's formulary. Estradiol 
vaginal insert, Estradiol transdermal patch, Yuvafem, and Estradiol oral tablets are on the Plan's formulary. 
You have not indicated why all alternatives required by the Plan would likely not be as effective for the 
enrollee as the requested drug; and/or would likely cause adverse reaction(s) or other harm to the enrollee. 
Therefore, an exception to the Plan's coverage criteria is not supported.  
 
Our Physician Reviewer's opinion is that formulary exception criteria are not met. 
 
A Plan must grant an exception for a drug that is not on its formulary if it determines that the requested 
drug is medically necessary, consistent with the prescriber?s statement. Based on a review of the available 
documentation, our Physician Reviewer's opinion is that formulary exception criteria are not met. 
Therefore, the Plan is not required to cover Estring.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that the enrollee needs this level of care as he 
does not have a caregiver able to meet his needs in the home. He would benefit from SNF care to allow him to 
regain strength enough to return home. The Plan denied your request. The Plan says the enrollee's needs are 
custodial. No daily skilled care is required. 
 
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 admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male who was 
hospitalized on 8/10/2020 with worsening leg swelling. The hospital discharge documentation shows he 
requires ongoing antibiotics for UTI treatment but that he has no fever or elevated white blood cells. The 
patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled 
professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a 
SNF. He does not have complex wound care or other ongoing SNF level SN need. His functional level does not 
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. He does not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. 
 
As a practical matter, this patient does not require the necessary services on 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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil for the enrollee.
You asked the Plan to pre-approve this drug. You say that these medication works best for the enrollee. 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 Tadalafil 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 pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that paramedics were called because your blood 
sugar had dropped dangerously low and you were unresponsive. The responders were able to treat you and they 
stayed with you until your blood sugar had risen to a normal level. You say that you were told that the 
paramedics could transport you to the hospital, however the hospital would discharge you because your blood 
sugar levels were now normal. You asked the Plan to reconsider providing coverage for the services. The Plan 
denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 1, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is not fully able to participate in a SNF level of activity. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with  the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not have 
complex wound care or other ongoing SNF level SN need. Her functional level does not require skilled therapy 
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively 
provide medically necessary and reasonable treatment in a SNF. She does not require skilled nursing or skilled 
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this 
enrollee does not require the necessary services on 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 admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
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 for the enrollee. 
 
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 the enrollee is safe for discharge home. 
 
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 the patient's nursing, medical and rehabilitation needs do not require an on-going acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical 
therapy and occupational therapy services but based on the medical records provided the patient does not 
require on-going care with an intensive inpatient rehabilitation therapy program. Our physician reviewer found 
that the enrollee's 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 for the enrollee.
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 for the enrollee. 
 
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 the enrollee can safely receive the services needed 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. 
Records do not indicate that there are significant, or complex medical/nursing issues that could not be 
addressed at a lower level of care. Ongoing pain medication and other medication management, wound/skin 
and oxygen care, and daily therapy can be provided at a lower level of care. Our physician reviewer found that 
the enrollee's 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of teprotumumab (Tepezza). 
 
You asked the Plan to pre-approve Tepezza. You say that you are appealing. The Plan denied your request. The 
Plan says the denial of authorization for this drug is correct, because the enrollee does not meet the criteria for 
use of this drug. 
 
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 Tepezza. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Tepezza. Our physician reviewer found the 
use of Tepezza is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. The use of 
Tepezza in this case is not supported by major drug compendia or by clinical research that appears in a 
Medicare-approved medical journal. The documentation deos not support that the requested Tepezza would be 
safe and effective and otherwise medically reasonable and necessary for the 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 Tepezza have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of teprotumumab (Tepezza).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
January 6, 2020 to January 14, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were transferred to 
a second hospital and should only be charged $1,875 and not $3,000. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
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 $375 
copayment for each day for days 1 to 5 for in-network Medicare-covered hospital care and $0 copayment for 
additional Medicare-covered days.  
 
You have been asked to pay a $375 copayment for each day, days 1 to 5 of the inpatient hospital stay. ($375 x 
5 = $1,875). The inpatient hospital stay falls within the ?Inpatient Hospital Care? 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 the inpatient hospital stay provided from January 6, 2020 to January 
14, 2020.