Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says the enrollee must have a history of osteoporosis-related fracture OR has 
tried and failed, or have a contraindication to zoledronic acid. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the Plan's 
step therapy criteria have not been met. Our physician reviewer found the enrollee is with osteoporosis, the 
diagnosis has been confirmed with a bone density scan. The enrollee has no history of an osteoporosis-related 
fracture. He has failed alendronate due to severe acid reflux, Prolia injections have been requested. 
 
Based on the medical records provided the enrollee has not tried and failed the required drug. Based on the 
medical records provided there is no indication that the plan's required drug would likely be less effective 
and/or likely have adverse effects 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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on May 5, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 provided on May 5, 2020 by 
an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a stay at a SNF in April and May of 2020. 
 
You asked the Plan to waive the copayment for a stay at a SNF. You say that you are on a fixed income and 
would be grateful for any assistance with the copayment. 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 $100 
copayment per day for days 21-100 of Medicare-covered SNF stays.  
 
You have been asked to pay a copayment of $2,060.32 for days 21-50 of a stay at a SNF. A stay at a SNF falls 
within the "Skilled nursing facility (SNF) care" benefit category. This means that you have been asked to pay 
less than the full 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 stay at a SNF in April and May of 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower jaw bone graft (21215) and a face bone graft 
(21210). 
 
You asked the Plan to pre-approve the lower jaw bone graft and face bone graft. You say that these services are 
medically necessary. The Plan denied your request. The Plan says Medicare does not cover routine dental 
services, and your plan does not provide coverage for these specific services. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
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 lower jaw bone graft and face bone 
graft. Our reviewer says that these services are not medically necessary. Our physician reviewer found there is 
no medical primary area of concern where the treatment requested would be necessary in order to treat a 
primarily medical condition.  Our reviewer found that the treatment is wholly focused on reconstruction of the 
dental arch to allow for improved dental functioning. Our physician reviewer also found that under the 
Medicare rules, the requested treatment is clearly dental in nature and would not be considered a covered 
service. 
 
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 lower jaw bone graft and face bone graft have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a lower jaw bone graft (21215) and a face bone graft 
(21210).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA). 
 
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 medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that RFA is covered when specific criteria are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic neck pain. She 
had RFA of the left C2 to C5 facet joints and initially had greater than 80 percent pain relief; however, the 
relief lasted only five months. The criteria for coverage are not met, as there is not at least six months of pain 
relief. Repeat RFA is therefore not reasonable or medically necessary. 
 
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 repeat radiofrequency ablation (RFA).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scalings and root planings (D4341) of the UR and UL 
quadrants. 
 
You asked the Plan to pre-approve the scalings and planings of the UR and UL quadrants. You say that this 
enrollee highly requires this service due to high caries, decay, and moderate periodontitis. The Plan denied your 
request. The Plan says that the documentation does not demonstrate evidence of significant bone loss and/or 
radiographic root-surface calculus on 4 or more teeth per quadrant. 
 
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 scalings 
and planings of the UR and UL quadrants when the services are medically necessary and reasonable. 
 
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 scalings and planings of the UR and 
UL quadrants. Our reviewer says that the periodontal scalings and root planings meet coverage criteria. Our 
physician reviewer found the documentation provided meets the  criteria for coverage for periodontal scaling 
and root planing (D4341) in the maxillary right and left quadrants due to the abnormal periodontal pockets 
(>4mm) and calculus deposits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scalings and planings of the UR and UL quadrants have been met. 
Therefore, we decided that the Plan has to pre-approve periodontal scalings and root planings (D4341) of the 
UR and UL quadrants.  
 
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: Favorable

 
We decided that the Plan has to pre-approve periodontal scalings and root planings (D4341) of the upper right, 
upper left, lower right, and lower left quadrants. 
 
You asked the Plan to pre-approve the scalings and planings. You say that the enrollee needs this service 
because they presented with pocket depths greater than 4mm, with generalized plaque and calculus. The Plan 
denied your request. The Plan says that the documentation does not demonstrate evidence of significant bone 
loss and/or radiographic root-surface calculus on 4 or more teeth per quadrant. 
 
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 scalings 
and planings when the services are medically necessary and reasonable. 
 
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 scalings and planings. Our reviewer 
says that the services meet coverage criteria. Our physician reviewer found the documentation provided meets 
the criteria for coverage for periodontal scaling and root planing (D4341) in all four quadrants on the basis of 
abnormal periodontal pocketing, bone loss and subgingival calculus deposits. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the scalings and planings have been met. Therefore, we decided that the Plan 
has to pre-approve periodontal scalings and root planings (D4341) of the upper right, upper left, lower right, 
and lower left quadrants.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Plenvu powder packets. 
 
You asked the Plan to pre-approve Plenvu. You say that this drug is medically necessary. The Plan denied your 
request. The Plan says this medication is not eligible for coverage under the Part B medical benefit. 
 
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 Plenvu powder packets.  
 
Benefits for Plenvu 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 pay for the medical services provided on October 8, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the home visit (99336) and advanced care planning (99497). You say that you 
would like reconsideration because it is the responsibility of the facility to obtain prior authorization. The Plan 
denied your request. The Plan says it was not medically necessary for this patient to receive care from an out of 
network provider for non-urgent/emergent 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 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 provided on October 8, 2019 
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services to be performed by an out-of-
network provider. 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says services are only covered by your Plan for in-network dentists. 
 
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 health plan contract says that the Plan will not pay for services you receive from an out-of-network dentist. 
If you receive services from an out-of-network dentist, you will be responsible for all costs related to those 
services. 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 the dental services to be performed by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the requested physician's services. 
 
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the 
enrollee must receive care from an in-network provider. In most cases, care received from an out-of-network 
provider will not be covered. 
 
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 items/services. Therefore, we decided that the Plan does not have to pre-approve the 
requested physician's services.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on March 4, 2020. 
 
You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says the member 
was enrolled in Hospice from January 20, 2020 to March 9, 2020. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for anesthesia services provided on March 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on March 4, 
2019. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you disagree with the charges 
because you had to be transferred to another facility for a surgical procedure. The Plan denied your request. 
The Plan says the claims were processed correctly and you are being charged the correct 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 $225 
copayment for ambulance services.  
 
You have been asked to pay a $225 copayment for ambulance services. Ambulance services fall within the 
ambulance services 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 ambulance services 
provided on March 4, 2019.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 23, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were rendered by an out-of-network provider without prior authorization. 
 
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 laboratory services provided on May 23, 2020 
by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested services have been found to be not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services are not medically reasonable or necessary. Our physician reviewer found in this case, the 
documentation doesn?t support that you require skilled nursing services or skilled rehab services to provide 
treatment that is medically necessary. You do not require skilled nursing or rehab services to effectively 
provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to 
maintain your condition and/or prevent deterioration. There is no indication of a recent hospitalization or 
change in functional status. There are no skilled nursing such as complex wound care, parental medications or 
care of a feeding tube. You have been medically stable without acute exacerbations of chronic medical 
conditions. 
 
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 home health services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Atovastatin Calcium. 
 
You asked the Plan to pre-approve Atovastatin Calcium. You say that you would like the Plan to reconsider 
their denial. The Plan denied your request. The Plan says Atovastatin Calcium is not covered by the enrollee's 
Medicare Part B benefit. 
 
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 Atovastatin Calcium.  
 
Benefits for Atovastatin Calcium 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology services rendered on March 17, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claim is a duplicate. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. 
 
We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the 
Plan on a separate claim for the same date of service. It is inappropriate to bill both the global and PC/TC 
components. 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 pay for the cytopathology services rendered on March 17, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional facet joint injection for the enrollee. 
 
You asked the Plan to pre-approve the additional injection. You say that this is medically necessary. The Plan 
denied your request. The Plan says the request is for a sixth cervical session in the last twelve rolling months. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than five facet joint injections in the 
cervical spine are covered per rolling 12 month year. 
 
We looked at the file, and Medicare rules. Five cervical injections have been approved and performed since 
2/12/20, on the following dates: 
 
2/12/20 
2/27/20 
3/27/20 
6/2/20 
7/13/20 
 
A sixth injection exceeds the Medicare allowed limit for this service. Based on this information, we decided 
that Medicare rules for coverage of the additional injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional facet joint injection for the enrollee.