Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for specialist services provided on October 23, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and paid. 
The Plan denied your request. The Plan says prior authorization was not obtained. 
 
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 specialist services provided on October 23, 2020 
by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on June 9, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the claim was not submitted with an appropriate type of bill (TOB) code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as 
billed due to the omission of an appropriate TOB code. Medicare rules for coverage of this service have not 
been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on 
June 9, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to provide Neulasta, pegfilgrastim 6mg (J2505). 
 
You asked the Plan to provide Neulasta, pegfilgrastim 6mg (J2505). You say that you want the enrollee treated 
with this drug. The Plan denied your request. The Plan says that the off-label use of this drug for the enrollee's 
condition is not medically accepted per Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to provide Neulasta, pegfilgrastim 6mg (J2505). Our 
reviewer says that the drug is approved. Our physician reviewer found the use is supported by clinical research 
that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not 
recommended in any of the compendia. The requested drug is safe and effective and otherwise reasonable and 
necessary for this enrollee. The risk of neutropenic fever in this immunocompromised patient is benefited by 
the use of Neulasta which is safe and effective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta, pegfilgrastim 6mg (J2505) have been met. Therefore, we decided that 
the Plan has to provide Neulasta, pegfilgrastim 6mg (J2505).  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the group 2 heavy duty power wheelchair (K0825). 
 
You asked the Plan to pre-approve the group 2 heavy duty power wheelchair. You say that you would like 
reconsideration because this wheelchair is medically necessary. The Plan denied your request. The Plan says 
the submitted documentation does not include a home assessment. 
 
The Plan must follow Medicare rules. Medicare rules say that a power wheelchair is covered if the 
beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the power wheelchair that is provided.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the group 2 heavy duty power wheelchair have not been met. Specifically, the documentation 
submitted does not include a home assessment to verify if your home provides adequate access between rooms, 
maneuvering spaces and surfaces for the operation of the requested equipment. Therefore, we decided that the 
Plan does not have to pre-approve the group 2 heavy duty power wheelchair (K0825).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B drug and the injection provided 
on September 1, 2020. 
 
You asked the Plan to waive the cost share for the Part B drug and the injection. You say that the provider did 
not mention the coinsurance for the medication prior to receiving the service. 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 20% 
coinsurance for Medicare Part B prescription drugs and a $20 copayment per visit to a specialist.  
 
You have been asked to pay a total of $195.40 for the Part B drug and the injection. The Part B drug falls 
within the ?Medicare Part B prescription drugs? benefit category. The injection falls within the ?Physician/  
Practitioner services, including doctor?s office visits? benefit category. See chart below.  
 
Date of Service Service Allowed Amount Copayment/Coinsurance Member 
Liability 
September 1, 2020 Part B 
medication 
$876.96 20% $175.40 
September 1, 2020 Injection $93 $20 $20 
Total    $195.40 
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 cost share for the Part B drug and the injection provided on 
September 1, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that you are in extreme discomfort and need arch 
supports. 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 foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150) and 
extraction of erupted tooth (D7210). 
 
You asked the Plan to pre-approve the comprehensive oral evaluation and extraction of erupted tooth. You say 
that these services are medically necessary for your condition. The Plan denied your request. The Plan says 
these services are not covered when performed by an oral surgeon. 
 
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 
comprehensive oral evaluation and extraction of erupted tooth when the services are performed by a 
participating general dentist. 
 
We looked at the file and Medicare rules. The file indicates that the services will be performed by an oral 
surgeon and not a participating general dentist. Based on this information, we decided that the Plan's rules for 
coverage of the comprehensive oral evaluation and extraction of erupted tooth have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the comprehensive oral evaluation (D0150) and 
extraction of erupted tooth (D7210).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Freestyle Libre Continuous Glucose Monitor. 
 
You asked the Plan to pre-approve the Continuous Glucose Monitor. You say that you would like 
reconsideration because you are experiencing poor circulation with your fingers turning purple and you are 
unsure how accurate your blood glucose readings are. The Plan denied your request. The Plan says you do not 
meet Medicare coverage criteria as you are not insulin treated. 
 
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 you do not use insulin with at least 
three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of the Continuous Glucose 
Monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle 
Libre Continuous Glucose Monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inhalation of nitrous oxide/analgesia (D9230).

You asked the Plan to pre-approve the inhalation of nitrous oxide/analgesia. You say that this service has always been covered in the past. The Plan denied your request. The Plan says this service is not listed as a covered code, and is excluded from coverage.

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 inhalation of nitrous oxide/analgesia (D9230).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751). 
 
You asked the Plan to pre-approve a crown. You say that the service should be covered. The Plan denied your 
request. The Plan says this service is not covered as it exceeds the benefit allowance. 
 
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. Specifically, records indicate you have already exhausted your $500 
supplemental allowance for dental services; you are responsible for any costs over the allowed amount. This 
means the requested service is not covered. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the repair of the complete upper and lower denture. 
 
You asked the Plan to pre-approve these services. You say that you require the dentures. The Plan denied your 
request. The Plan says that this 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 the 
repair of the complete upper and lower denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor. 
 
You asked the Plan to pre-approve therapeutic continuous glucose monitor. You say that you are appealing. 
The Plan denied your request. The Plan says the denial of authorization for this device is correct. 
 
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 you do not 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. Based on this information, we decided 
that Medicare rules for coverage of therapeutic continuous glucose monitor have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone graft at time of implant placement (D6104). 
 
You asked the Plan to pre-approve bone graft at time of implant placement. You say that the services requested 
are medically necessary. The Plan denied your request. The Plan says this service is not covered under your 
supplemental 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 
bone graft at time of implant placement (D6104).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the insertion of posterior spinal instrumentation at base 
of neck for stabilization, 1 interspace for the enrollee. 
 
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 the member does not have significant disc disease, spinal stenosis, 
neuroformainal narrowing, instability, or bony abnormalities to support medical necessity for this intervention. 
 
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 medical records 
do not show any evidence of spinal instability, fracture, or lesion. There is no severe spinal stenosis or 
neurologic deficit. Our physician reviewer found that the enrollee's condition does not meet criteria for 
coverage of 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 insertion of posterior spinal instrumentation at base of neck for stabilization, 1 
interspace for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pulp cap. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pulp cap.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a walk-in tub. 
 
You asked the Plan to pre-approve a walk-in tub. You say that a walk-in tub is medically necessary. The Plan 
denied your request. The Plan says a walk-in tub is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.  A walk-in tub does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a walk-in tub.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Xeljanz XR 11 mg tablet. 
 
You asked the Plan to pre-approve Xeljanz. You say that this service is medically necessary. The Plan denied 
your request. The Plan says this medication does not fall under Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Xeljanz XR 11 mg 
tablet.  
 
Benefits for Xeljanz 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 pre-approve BRCA 1 and 2 testing. 
 
You asked the Plan to pre-approve the testing. You say that you should not have to have cancer before getting 
approved for this testing. The Plan denied your request. The Plan says there is no personal history of cancer. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed above, are not covered. 
 
The test at issue in this appeal, the testing, is being requested solely for screening purposes. Medicare does not 
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-approve 
BRCA 1 and 2 testing.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided to the enrollee from January 
1, 2020, to March 21, 2020. 
 
You asked the Plan to pay for this service. You say that these services should be covered by the Plan. The Plan 
denied your request. The Plan says this is an administrative determination for coding. The Plan says that the 
distinct 5 position HIPPS codes, 3CHK4, is invalid for HH PPS periods of care beginning on and after January 
1, 2020. Therefore, per the Medicare guidelines, the rules for payment of the January 01, 2020 through January 
30, 2020 and February 01, 2020 through March 21, 2020, claims have not been met. The Plan states a corrected 
claim would be reviewed if submitted.  
 
 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes. In this case the claim submitted cannot be paid as 
billed due to coding errors on the claim positions themselves. Medicare billing criteria are not met.  
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not 
have to pay for home health services provided to the enrollee from January 1, 2020, to March 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a primary closure of sinus perforation (D7261) and a 
bone replacement graft for ridge preservation (D7953) for tooth #15. 
 
You asked the Plan to pre-approve the dental services. You say that you have bad sinus and tissue. You say that 
there is an opening. You also say that steroids can cause a yeast infection. The Plan denied your request. The 
Plan says primary closure of sinus perforation is not listed as a covered service. The Plan says bone 
replacement graft for ridge preservation is not listed as a covered service. The Plan also says that services not 
listed are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
primary closure of sinus perforation (D7261) and a bone replacement graft for ridge preservation (D7953) for 
tooth #15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup for tooth #8. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered service. 
 
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 for tooth #8.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the $25 copayment charged for imaging services provided out 
of network on May 15, 2020.  
 
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The 
Plan denied your request. The Plan says this copayment was charged based on the services provided and the 
Plan contract agreement. 
 
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 $25 
copayment for imaging services both in and out of network. 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 $25 copayment charged for 
imaging services provided out of network on May 15, 2020.