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

 
We decided that the Plan does not have to pre-approve Eliquis tablets. 
 
You asked the Plan to pre-approve Eliquis tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Eliquis tablets are not covered under 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 Eliquis tablets.  
 
Benefits for Eliquis tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta. 
 
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 Original Medicare covers clinical trials. 
 The Plan must follow Medicare rules. the rules say that Original Medicare is responsible for the costs 
associated with clinical trials. 
 
We looked at the file and Medicare rules. The file shows that the services at issue are being requested as part of 
a clinical trial. The claim for these services should be submitted to Original Medicare. Therefore, we decided 
that the Plan does not have to pre-approve Neulasta.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the podiatry visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the podiatry visit. You say that you were told your podiatrist was in-network 
when you changed insurance. The Plan denied your request. The Plan says the provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide 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 podiatry visit to be provided by an out-of-network (OON) provider.
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 this is medically necessary for the enrollees 
treatment of her foot condition as she has failed other conservative care options including icing, medication, 
injection and shoe gear changes, and continues experiencing pain after her 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 foot orthotics.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says IRF care is 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 in the Medicare rules section. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for posterior laminectomy for cord compression. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha Sure. 
 
You asked the Plan to pre-approve Repatha Sure. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the enrollee does not have Part D coverage under 
this contract. The Plan says that the enrollee has Verizon, which provides its own pharmacy benefits. 
 
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 Repatha Sure.  
 
Benefits for Repatha Sure 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are 
medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not 
meet criteria. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 additional PT visits. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have had prior OT and the documentation does not reveal that 
you require the unique skills of a professional therapist to safely and effectively provide treatment, or that the 
services can be safely and effectively performed only by a therapist, or by or under the supervision of a 
therapist beyond the approved additional 6 visits. You should be able to transition to an independent HEP. The 
requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of 
a qualified therapist is not required to establish, design and/or deliver a program to maintain your current 
condition or to prevent or slow further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does 
not have to pre-approve ten (10) additional physical therapy (PT) visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight (8) additional OT visits. 
 
You asked the Plan to pre-approve additional OT visits. You say that the OT is medically necessary. The Plan 
denied your request. The Plan says eight (8) additional OT visits are not medically necessary. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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-approved eight (8) additional OT visits. Our 
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration 
of the enrollee's condition. Our physician reviewer found that the additional requested therapy generally is 
accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior OT and the 
documentation does not reveal that the enrollee requires the unique skills of a professional therapist to safely 
and effectively provide treatment, or that the services can be safely and effectively performed only by a 
therapist, or by or under the supervision of a therapist. The enrollee has been approved ample therapy with time 
for a transition to a robust independent home exercise program. The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow 
further deterioration. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of eight (8) additional OT visits have not been met. Therefore, we decided that the 
Plan does not have to pre-approve eight (8) additional OT visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Methotrexate tablets 2.5mg 
 
You asked the Plan to pre-approve Methotrexate tablets. The Plan denied your request. The Plan says 
Methotrexate is a self-administered drug. The Plan also says that Methotrexate is covered under the pharmacy 
benefit and not the 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 Methotrexate tablets 2.5mg  
 
Benefits for Methotrexate tablets may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), 
endodontic therapy, anterior tooth (excluding final restoration) (D3310), and prefabricated post and core in 
addition to crown (D2954) provided November 1, 2021. 
 
You asked the Plan to pay for the limited oral exam, root canal and prefabricated post and core. You say that 
this service was necessary to replace a broken front tooth. The Plan denied your request. The Plan says these 
services are not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), endodontic therapy, anterior tooth (excluding final 
restoration) (D3310), and prefabricated post and core in addition to crown (D2954) provided November 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), periapical x-ray 
(D0220), and surgical extraction (D7210) provided on October 25, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had a painful infected tooth. You say that x-
rays helped determine the tooth could not be saved. You also say that this should be classified as a medical 
emergency. The Plan denied your request. The Plan says routine dental services are 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 limited oral evaluation 
(D0140), periapical x-ray (D0220), and surgical extraction (D7210) provided on October 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), additional 
intraoral periapical x-ray (D0230), clinical crown lengthening (D4249), and fixed partial denture sectioning 
(D9120) provided on September 20, 2021. 
 
You asked the Plan to pay for the intraoral periapical x-rays, clinical crown lengthening, and fixed partial 
denture sectioning. You say that you believe that x-rays were covered under your plan. The Plan denied your 
request. The Plan says these services are not covered expenses under your dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the first 
intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), clinical crown lengthening 
(D4249), and fixed partial denture sectioning (D9120) provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and ten (10) 
teeth extractions (D7140). 
 
You asked the Plan to pre-approve a comprehensive oral evaluation and teeth extractions. You say that you are 
diabetic, and you have COPD. You were informed that you are at high risk if you do not get the extractions. 
You also say you are very embarrassed and was teased by children because of your teeth. The Plan denied your 
request. The Plan says you receive coverage for dental services when they are performed by a participating 
general dentist. Dental services performed by an oral surgeon 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 Plans 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 
comprehensive oral evaluation (D0150) and ten (10) teeth extractions (D7140).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve the specialist office visit. You say that you would like to see this provider 
since you saw them in the past. The Plan denied your request. The Plan says there are multiple in-network 
providers that provide the same quality of 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 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 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 
a specialist office visit 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 pay more for inpatient hospital services provided from December 23, 
2020, To January 8, 2021. 
 You asked the Plan to pay more for the inpatient hospital services. You say that this diagnosis is supported, and 
the original diagnosis related group (DRG) should be paid. The Plan denied your request. The Plan says 
diagnosis N17.0 is not substantiated in the medical record which resulted in a lower DRG. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code N17.0. 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 more for the inpatient hospital services. Our reviewer says that diagnosis 
code N17.0 (acute kidney failure with tubular necrosis) is not supported by the medical record. Our physician 
reviewer found the diagnosis of acute tubular necrosis (ATN) is a specific form of kidney injury that denotes 
significant damage to the proximal tubules. The diagnosis cannot be made from a rise in creatinine alone. To 
validate the diagnosis of ATN the criteria for acute kidney injury (AKI) must be met first followed by either 
renal biopsy confirmation with treatment or at least two of the following criteria: 1) an ischemic / toxic 
etiology; or 2) a urinalysis with non-hyaline casts; or 3) a urinary spot sodium > 40mEq/L; or 4) a FeNa > 2%. 
In this case, the creatinine range during the admission was 0.9 to 1.4. The highest creatinine was only slightly 
above the facility's upper limit of normal which was noted to be 1.3. In addition, there was no urinalysis found 
in the records available for review, no urine electrolytes were obtained, and there was no renal biopsy found to 
support the condition.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
more for inpatient hospital services provided from December 23, 2020, To January 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extraction (D7140) provided on September 16, 2021. 
 
You asked the Plan to pay for the simple extraction. The Plan denied your request. The Plan says this service is 
not covered by your dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the simple 
extraction (D7140) provided on September 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two crowns (D2750 x2), core buildup, including any pins 
when required (D2950), and endodontic therapy (D3320) provided on July 16, 2021 by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the crowns, core buildup, and endodontic therapy. You say that you were advised 
by several agents, prior to receiving these services, that you would be reimbursed. The Plan denied your 
request. The Plan says services provided by an OON or non-contracted provider are not provided under this 
benefit program. The Plan also says that services are only covered by your Health Plan for in network dentists. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the two 
crowns (D2750 x2), core buildup, including any pins when required (D2950), and endodontic therapy (D3320) 
provided on July 16, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2393) provided on November 30, 2021. 
 
You asked the Plan to pay for the resin-based composite. You say that you have gum disease and have to get 
them cleaned 3 times per year. You also say that you broke a tooth and need a filling. The Plan denied your 
request. The Plan says your benefits for this service have been satisfied and the frequency limitation has been 
exceeded. 
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, restorations are limited to two 
procedure codes per calendar year. The record shows that you received two resin-based composites (D2391 and 
D2393) on March 19, 2021 and your restorations benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pay for the resin-based composite (D2393) provided on November 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on November 8, 2021. 
 
You asked the Plan to pay for the gingival irrigation. You say that you were told by the provider's dental 
hygienist that this service should be paid by your insurance. The Plan denied your request. The Plan says this 
service is not covered by your health plan or Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation (D4921) provided on November 8, 2021.