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

 
We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) and 
prophylaxis - adult (D1110) provided September 27, 2021, and the resin-based composite - one surface, 
anterior (D2330) provided October 13, 2021. 
 
You asked the Plan to pay for the periodic oral exam, dental cleaning and filling. You say that you would like 
these services covered. The Plan denied your request. The Plan says these services are not covered because the 
provider has opted out of Medicare. 
 
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.  
 
We looked at the file and Medicare rules. The services at issue in this appeal were provided in a non-urgent, 
non-emergent situation by the provider who has opted out of the Medicare program. Based on this information, 
we decided that the Plan's rules for coverage of the periodic oral exam, dental cleaning and filling have not 
been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established 
patient (D0120) and prophylaxis - adult (D1110) provided September 27, 2021, and the resin-based composite - 
one surface, anterior (D2330) provided October 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal 
implants (D6010). 
 
You asked the Plan to pre-approve the endosteal implants. The Plan denied your request. The Plan says this 
service is not covered under your benefit plan. 
 
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 
surgical placements of implant bodies: endosteal implants (D6010).
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 based on the documentation provided you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services 
and regular physician evaluation. Your care needs can be met at a lower level of care. 
 
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 pay more for the sinus augmentation with bone or bone substitutes 
(D7951) provided on October 28, 2021. 
 
You asked the Plan to pay more for the sinus augmentation. You say that this service was a necessary 
procedure and you feel it should be covered. The Plan denied your request. The Plan says the remaining annual 
dental allowance of $205 was applied toward this service, and the full annual allowance of $2,000 has been 
met. The Plan also says that you are responsible for any amount above and beyond the allowance amount. 
 
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 Plan offers a $2,000 combined 
allowance for supplemental preventive and comprehensive dental services every year. The contract says that 
you are responsible for any amount over and above the allowance amount. The record shows that you met the 
annual maximum benefit while processing this claim for the October 28, 2021 date of service and your annual 
maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the 
sinus augmentation with bone or bone substitutes (D7951) provided on October 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve OON services. You say that you have been following this chiropractor for 
10 years. The Plan denied your request. The Plan says the service would be covered when performed by a 
contracted provider. 
 
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 
chiropractic services to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional home health physical therapy visits. 
 You asked the Plan to pre-approve home health physical therapy services. You say that home health physical 
therapy services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan 
says the criteria for coverage have not been met. 
 
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 home health physical therapy services. 
Our reviewer says that the requested home health physical therapy services are not medically reasonable and 
necessary. Our physician reviewer found that the enrollee is a 95-year-old woman with a history of falls/fall 
risk starting on November 10, 2020. The enrollee has a sacral ulcer with tunneling. The enrollee has a 
persistent ulcer on the lateral aspect of her right leg. The enrollee has scattered small pressure lesions, 
unstageable deep tissue injuries on her foot. In this case, the records do not demonstrate that continued skilled 
therapy services are required to effectively provide treatment, care, and/or services in order to improve the 
enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of 
function and/or to prevent 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 home health physical therapy services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 6 additional home health physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a surgical placement of an implant body (D6010) provided 
on August 3, 2021. 
 
You asked the Plan to pay for surgical placement of an implant body. You say that you feel these services 
should be covered or the co-pays waived because the Plan has embedded dental services that allow up to 
$10,000 for the calendar year benefit. The Plan denied your request. The Plan says the requested service for a 
surgical placement of an implant body is not a covered benefit under your Plan and you are responsible for the 
full payment. 
 
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 a surgical 
placement of an implant body (D6010) provided on August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Freestyle libre 14-day sensor (K0553), provided on 
August 8, 2021. 
 
You asked the Plan to pay for the Freestyle libre 14-day sensor. You say that the item was medically necessary. 
The Plan denied your request. The Plan says there is missing documentation. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. There is no signed and dated document indicating the 
enrollee received this item and the documentation that was submitted does not match the date of service. The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the Freestyle libre 14-day sensor (K0553), 
provided on August 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gamunex-C for the enrollee. 
 
You asked the Plan to pre-approve Gamunex-C. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee does not have any stated contraindications to the preferred products. 
 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 Gamunex-C. Our reviewer says that 
Gamunex-C is not medically reasonable and necessary. The Plan requires a trial of Privigen before they will 
approve the requested drug. In this case, the patient has not tried and failed the required drug. There is no 
documentation provided indicating that the Plan's required drug would likely be less effective and/or likely 
have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet 
step therapy criteria for Gamunex-C. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gamunex-C have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Gamunex-C for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve battery replacement for a power wheelchair. 
 
You asked the Plan to pre-approve battery replacement. You say that you must still use your current power 
wheelchair inside your home, which is why you need the battery. The Plan denied your request. The Plan says 
the denial of authorization for this service is correct, because you do not need a power wheelchair and you 
received an evaluation for a power scooter instead. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. Medicare rules state that Medicare does not cover the replacement of durable medical equipment due to wear during the reasonable useful lifetime of equipment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of battery replacement for a power 
wheelchair. have been met. No records were submitted regarding the age or condition of your current power 
wheelchair or its batteries. Without this information, we cannot determine whether your power wheelchair 
battery has exceeded its reasonable useful lifetime or if replacement is appropriate at this time. Your treating 
provider evaluated you for a power operated vehicle (power scooter). Please follow up with your provider 
regarding an evaluation of your current power wheelchair or the request for a power scooter. Therefore, we 
decided that the Plan does not have to pre-approve battery replacement for a power wheelchair.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a colonoscopy (45378).
You asked the Plan to pre-approve a colonoscopy. You say that the operative notes and available pathology notes from the enrollee's previous 2 colonoscopies suggest that the service is medically necessary. The Plan denied your request. The Plan says that the requested service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 colonoscopy. Our reviewer says that the requested colonoscopy is considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee underwent a colonoscopy in 2011 and had one poly removed. The reviewer found that the enrollee's first surveillance colonoscopy was greater than five years ago. Therefore, the reviewer found that the record provided establishes the medical necessity and reasonableness, as defined by Medicare rules, of the requested 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 a colonoscopy have been met. Specifically, the file shows that no adenomas were found on the first surveillance colonoscopy. Therefore, we decided that the Plan has to pre-approve a colonoscopy (45378).
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 a non-spinal electric bone growth (osteogenesis) 
stimulator (BGS) coded as E0747. 
 
You asked the Plan to pre-approve the electric BGS. You say that the enrollee underwent right ankle and distal 
tibiofibular joint arthrodesis in August 2021. Her computed tomography (CT) scan from February 2022 showed 
no signs of healing. At this time, use of the BGS is needed to promote healing and fusion. The Plan denied your 
request. The Plan says a joint fusion is not considered failed until 9 months have passed since the last surgery. 
This has not yet occurred. 
 
The Plan must follow Medicare rules. Medicare rules say that BGS is considered medically necessary for 
enrollees with failed fusion of a joint other than in the spine where a minimum of nine months has elapsed 
since the last surgery. 
 
We looked at the file and Medicare rules. As only 7 months have passed since the fusion surgery, a failed 
fusion does not exist per Medicare rules. The BGS does not meet coverage criteria at this time.  Therefore, we decided that the Plan does not have to pre-approve a non-spinal electric bone growth 
(osteogenesis) stimulator (BGS) coded as E0747.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and are currently unstable for transfer to an LTACH.
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. You appear to be improving gradually but still requires only short-term acute care services that can safely be administered at the current facility until stable for a lower level of care. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says the drug is not medically necessary for the enrollee's criteria. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 pre-approve Keytruda. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been 
diagnosed with biliary cancer. The tumor mutational burden (TMB) is low in this case and the enrollee has 
microsatellite stability (MSS). Single agent Keytruda could be approved for TMB greater than or equal to 10 or 
microsatellite instability (MSI). In this case, neither criteria have been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight home health physical therapy (PT) visits.
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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a left knee arthroplasty on January 10, 2022 and began home therapy on January 19, 2022. Per the home therapy evaluation on February 18, 2022 she is independent for bed mobility and supervision for transfers and ambulation. She is walking 230 feet with a rollator walker. She has been instructed on safety measures, an emergency plans, and fall precautions. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve her level of function, or to establish/perform a maintenance program to maintain the her level of function and/or prevent deterioration. The enrollee has progressed to a high functional level and has been trained in a home exercise program. She has had education in safety. Ongoing skilled professional services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve eight home health physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided 
on March 25, 2021. 
 
You asked the Plan to pay for the topical application of fluoride varnish. You say that you have been going to 
the same provider since 2016 and have never had problems with a provider at the facility being out-of-network. 
The Plan denied your request. The Plan says this service 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 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 pay for the 
topical application of fluoride varnish (D1206) provided on March 25, 2021.