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

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing, upper left quadrant 
for the enrollee. 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there appear to be only three teeth present in the upper left 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 dental 
services 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 dental services. Our reviewer says 
that the requested dental services are not medically reasonable or necessary. Our physician reviewer found the 
documentation provided was not sufficient to meet the criteria for coverage for scaling and root planing for 
four or more teeth in the maxillary right and left quadrants. A review of the dental record and radiographs did 
not contain a record of periodontal charting nor a complete set of radiographs to determine the number of teeth 
in the quadrants 
 
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 dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planing, upper left quadrant for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services. 
 
You asked the Plan to pre-approve chiropractic services. The Plan denied your request. The Plan says this is 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
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 chiropractic services Our reviewer says 
that the requested chiropractic services are not medically reasonable and necessary. Our physician reviewer 
found that the submitted lumbar X-ray studies reveal musculoskeletal findings of mild thoracolumbar 
levoscoliosis and moderate degenerative change mid to lower lumbar spine, which do not reveal evidence of a 
subluxation. The submitted telehealth chart note/office visit note only reveals pain with range of motion in the 
back and does not reveal evidence of subluxation per Medicare guidelines. Thus, chiropractic treatment is 
neither supported, nor allowed, per Medicare guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve chiropractic services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Edaravone (J1301). 
 
You asked the Plan to pre-approve Edaravone. You say that Riluzole and Edaravone are the 2 current Food and 
Drug Administration approved medications to help with the enrollee's diagnosis. You also say that the enrollee 
has tried Riluzole, but was not tolerated, and is now pursuing Edaravone. The Plan denied your request. The 
Plan says this drug is a non-formulary drug that the Plan approved for you under the formulary exception 
process. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Edaravone (J1301).  
 
Benefits for Edaravone 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 transthoracic echocardiography for the enrollee. 
 
You asked the Plan to pre-approve the test. You say that this is needed because of an abnormal nuclear stress 
test. The Plan denied your request. The Plan says the same test or similar was recently performed. 
 
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 test. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has symptoms concerning for possible coronary ischemia in addition to a recent 
echocardiogram and recent nuclear stress test, both with results that are not reported to be equivocal or limited 
in any way. In this circumstance of no documented clinical change and recent cardiac evaluation as outlined, 
the records do not support the medical necessity for repeat stress testing and repeat echocardiography.  
 
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 test have not been met. Therefore, we decided that the Plan does not have to 
pre-approve transthoracic echocardiography for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that that the enrollee and the enrollee's family were 
refusing SNF admission and requesting a reassessment for IRF admission. The Plan denied your request. The 
Plan says the enrollee does not meet medical necessity criteria for admission to an inpatient rehab unit. 
 
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 that based on the documentation provided, the health plan's denial should be 
upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The 
enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the care can be safely received in another setting, such as inpatient 
rehabilitation, or a skilled nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in 
general, LTACHs do not provide clinical services that are materially different than those of short-term acute 
care hospitals. In this case, ongoing care needs include oxygen supplementation, intermittent BiPAP support, 
oral diuretic and antihypertensive medications, surveillance laboratory studies, and therapy services. The 
documentation does not support that the enrollee in this case requires services at the LTACH that are not 
available at the acute care hospital where he is currently receiving care. There are no required medical services 
identified that are available at the LTACH, that are not available at the current health care setting being offered 
by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for emergency room visits provided on July 
20, 2020, through July 24, 2020. 
 
You asked the Plan to waive the copayments for the emergency room visits. You say that you should not be 
responsible for the copayments. 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 $90 
copayment for emergency care.  
 
You have been asked to pay a $90 copayment for each of the emergency room visits. The emergency room 
visits fall within the Emergency 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 copayments 
for emergency room visits provided on July 20, 2020, through July 24, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you do not want to start over with another 
therapist. The Plan denied your request. The Plan says a network gap does not exist. 
 
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 OON services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services to be provided by an out-of-network (OON) provider.
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 you need rehab. The Plan denied your request. The 
Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the submitted records show that 
you were admitted to the hospital for drainage from surgical wounds and trouble caring for yourself at home. 
Your medical conditions are stable. You have no medical needs that require an inpatient admission. You have 
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental pontic (D6241) and crown (D6751). 
 
You asked the Plan to pre-approve the pontic and crown. You say that these items are medically necessary. The 
Plan denied your request. The Plan says the requested dental services are not listed as a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
dental pontic (D6241) and crown (D6751).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta Onpro for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says the accepted use of this drug for your illness requires the medication will be used for 
regimens with high risk (>20%) of causing clinically significant febrile neutropenia or intermediate risk (10-
20%) with additional risk factors for febrile neutropenia 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found a review of the 
submitted documentation does not support that the criteria has not been met. Medical necessity cannot be 
determined. 
 
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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta Onpro for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and 
pelvis (74177). 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that this is medically 
necessary. The Plan denied your request. The Plan says that this is not indicated at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 a CT scan of the abdomen and pelvis. 
Our reviewer says that the criteria for coverage of the requested CT can have not been met. Our physician 
reviewer found the medical records indicate that the enrollee is very low risk and imaging is not 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 a CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis 
(74177).
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a pacemaker insertion (33208) and the insertion of pacing 
electrode (33225). 
 
You asked the Plan to pre-approve a pacemaker insertion and the insertion of pacing electrode. You say that 
this is medically necessary. The Plan denied your request. The Plan says that the documentation does not show 
that the enrollee has a high-grade AV block. 
 
The Plan follows Medicare rules. Medicare rules say that pacemakers and pacing electrodes are covered when 
medically necessary for the indications detailed 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 a pacemaker insertion and the insertion 
of pacing electrode. Our reviewer says that the requested services are medically necessary. Our physician 
reviewer found based on the records the patient had pacemaker placement about five years ago and now with 
documented pacemaker malfunction including lead malfunction and high pacing thresholds. In this setting of 
significant pacemaker malfunction a pacemaker device change is reasonable, appropriate and the standard 
accepted practice in the medical community. 
 
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 pacemaker insertion and the insertion of pacing electrode have been met. 
Therefore, we decided that the Plan has to pre-approve a pacemaker insertion (33208) and the insertion of 
pacing electrode (33225).  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal orthotic device (D7880) provided on June 8, 
2020. 
 
You asked the Plan to pay for the occlusal orthotic device. You say that you would like to be reimbursed for 
this service. The Plan denied your request. The Plan says routine dental care is not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for 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 pay for the occlusal orthotic device 
(D7880) provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on September 12, 2019, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network 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 September 12, 
2019, by an out-of-network (OON) provider.