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

We decided that the Plan does not have to pre-approve Fulphila. 
 
You asked the Plan to pre-approve Fulphila. You say that you would like reconsideration because this drug is 
medically necessary The Plan denied your request. The Plan says the clinical information received does not 
support the medical necessity of the requested medication. 
 
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 Fulphila. Our reviewer says that the 
requested regimen is associated with a low risk of febrile neutropenia (3%) and the NCCN recommends no 
routine prophylactic growth factor in this setting. Our physician reviewer found the review indicates that the 
documentation does not support that the Fulphila is medically reasonable and necessary for the member. The 
documentation does not support that the Fulphila is safe and effective for the member. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fulphila have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Fulphila.
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 appropriate care is being received in the IRF. 
 
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 there are no identifiable skilled nursing 
service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 
does 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from August 16, 2020, 
to September 5, 2020. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the requested 
service is not medically necessary. The Plan also says that the enrollee required no nursing services which 
would be considered skilled services by Medicare. 
 
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 the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from August 16, 2020, to September 5, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical extractions. 
 
You asked the Plan to pre-approve the surgical extractions. You say that your dentist informed you it would be 
best to go to an oral surgeon to have your teeth extracted because you were not able to be numbed. The Plan 
denied your request. The Plan says the surgical removal of erupted teeth is not covered by Medicare unless the 
extraction of teeth is to prepare the jaw for radiation nor is it covered by the Plan?s enhanced dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
surgical extractions.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide a therapeutic continuous glucose monitor. 
 
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that it is uncomfortable for 
the enrollee to continue using a glucometer. The Plan denied your request. The Plan says criteria is not met for 
a therapeutic continuous glucose monitor. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per 
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based 
on the blood glucose testing results. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have 
to provide a therapeutic continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panniculectomy (15830). 
 
You asked the Plan to pre-approve a panniculectomy. 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 follows Medicare rules. Medicare rules say that abdominal lipectomy/panniculectomy is covered 
when certain criteria is met. 
 
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 a panniculectomy. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the documentation does not 
support that the enrollee has a panniculus that hangs below the level of the pubis, and the medical records do 
not document that the panniculus causes chronic intertrigo that consistently recurs over three months while 
receiving appropriate medical therapy, or remains refractory to appropriate medical therapy over a period of 
three months. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a panniculectomy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a panniculectomy (15830).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you rely on these supplies to lead a 
normal life. The Plan denied your request. The Plan says that these items are not covered by Medicare. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: 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 service is medically necessary. The Plan denied 
your request. The Plan says the service is not medically necessary as it can be obtained at a lower 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 there are no complex nursing or rehabilitation needs and the patient does not require 
treatment by multiple therapies. There is not a reasonable expectation that this patient 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. Specifically, the enrollee does not require complex 
nursing or rehabilitation needs. This means the services can be obtained at a lower level of care and IRF care is 
not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute 
inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 18 naturopathic visits. 
 
You asked the Plan to pre-approve 18 naturopathic visits. You say that you originally joined this Plan for the 
naturopathy benefit and would like 18 visits covered like in previous years. The Plan denied your request. The 
Plan says only 6 visits are covered in the 2021 Plan year. 
 
The rules say that Medicare does not cover the services of a naturopath. However, the Plan offers a benefit that 
exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers up to 
6 visits with a naturopath every calendar year. 
 
We looked at the file and Medicare rules. The Plan covers only 6 visits a year. Based on this information, we 
decided that Medicare rules for coverage of 18 naturopathic visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 18 naturopathic visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical boot. 
 
You asked the Plan to pre-approve a surgical boot (L3260). You say that you will need a surgical boot after 
foot surgery. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a surgical boot.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexible base partial denture. 
 
You asked the Plan to pre-approve the dental item. You say that you need a partial denture with 5 teeth. You 
say that you need the denture so that you can eat. You also say that it is not cosmetic. The Plan denied your 
request. The Plan says the requested flexible base partial denture is not a covered service under your 
supplemental dental benefits. The Plan also says that a flexible base partial denture is not covered under your 
medical plan. 
 
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 flexible base partial 
denture is not among those covered under this benefit. Additionally, the flexible base partial denture 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 a flexible base partial denture.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device surgery. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that experimental and investigational procedures are not covered by 
Medicare. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The spacer remains 
experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found 
that your condition does not meet Medicare criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Vertiflex Superion device surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation treatment (proton beam therapy). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary and 
beneficial to the enrollee's health. The Plan denied your request. The Plan says there are not enough studies to 
prove this type of treatment works well for their cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found they agree that SBRT (stereotactic radiation) is indicated and proton beam therapy is not 
indicated. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiation treatment (proton beam therapy).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from 
December 1, 2019 to December 31, 2019. 
 
You asked the Plan to pay for home health services. You say that this should be covered. The Plan denied your 
request. The Plan says this was not billed with the required location code. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, these 
services were not reported with an appropriate Q code for the location of the services. Therefore, we decided 
that the Plan does not have to pay for the home health services provided to the enrollee from December 1, 2019 
to December 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Calcitonin salmon injection provided 
on June 29, 2020. 
 
You asked the Plan to waive the coinsurance for the Calcitonin salmon injection. You say that you thought the 
Plan would pay this claim. The Plan denied your request. The Plan says you were charged this coinsurance 
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 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay 20% coinsurance for the Calcitonin salmon injection. The Calcitonin salmon 
injection falls within the Medicare Part B prescription drugs benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the coinsurance for the Calcitonin salmon injection provided on June 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optimizer Smart system for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the denial for this procedure is unwarranted and 
unsupported by the patient's current medical status and is inconsistent with currently accepted medical practice. 
The Plan denied your request. The Plan says that a review of the current medical literature indicates that this 
service is considered experimental and investigational. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Based on the records 
the patient has refractory congestive heart failure. In this circumstance treatment with the Optimizer System 
device has been demonstrated in only one trial to help reduce hospital readmission compared to standard 
medical therapy. Moreover, the trial was very small (only 160 patients) and the results for the composite 
endpoint barely reached statistical difference (p=0.048). Therefore, the efficacy of the Optimizer System is still 
uncertain at this time according to leading authorities and not recommended in current guidelines for the 
treatment of heart failure. Our physician reviewer found that the enrollee's condition does not meet Medicare 
criteria for these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Optimizer Smart system for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for 4 skin substitute graft procedures (15271 x 
4) received on July 2 to July 30, 2020. 
 
You asked the Plan to waive the copayment for skin substitute graft procedures. You say that you were never 
informed of the cost for the requested procedures and were only told that your insurance had approved the 
procedures. The Plan denied your request. The Plan says the correct copayment was 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 $325 
copayment for each surgical service received at an outpatient hospital facility.  
 
You have been asked to pay $1,300, or a $325 copayment for each of 4 skin substitute graft procedures. Skin 
substitute graft procedures fall within the "Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers" 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 4 skin substitute graft procedures (15271 x 4) received on July 2 to July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 1, 2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for subsequent nursing facility care provided on January 1, 2020.