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

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921) provided by a participating 
provider. 
 
You asked the Plan to pre-approve gingival irrigation. You say that these services are medically necessary. The 
Plan denied your request. The Plan says the requested dental service is not 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 pre-approve 
gingival irrigation (D4921) provided by a participating provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan. 
 
You asked the Plan to pre-approve a computerized tomography (CT) scan. You say that you would like to 
request reconsideration of the denied authorization. The Plan denied your request. The Plan says we cannot 
approve the imaging because one of the following results must be noted: Chest x-rays taken while you are lying 
on your side or an ultrasound of your chest. Your records must show that you had a needle placed into the chest 
wall to remove as much of this fluid as could be removed. That fluid is then tested to help your doctor plan 
your treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
Based on this information, we decided that Medicare rules for coverage of a computerized tomography (CT) 
scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computerized 
tomography (CT) scan.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Entyvio (J3380). 
 
You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for Entyvio. 
 
 
 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 Entyvio. Our reviewer says that the 
enrollee does not meet the criteria for coverage for Entyvio. Our physician reviewer found there is no 
indication that the enrollee has tried and failed the required drug. Our physician reviewer also found that there 
is no indication that the Plan's required drug would likely be less effective and/or likely have adverse effects for 
the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio (J3380).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the physician services. You say that you were having trouble continuing 
treatment with your current provider. The Plan denied your request. The Plan says authorization was not 
obtained prior to services being rendered. 
 
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 
physician services to be provided by an out-of-network (OON) provider.
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 chiropractic services. You say that this provider is gentler than the other 
providers in the area. The Plan denied your request. The Plan says you need to be treated by an in-network 
provider for this service. 
 
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 
chiropractic services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that you been having trouble breathing 
for the last couple of months and your physician ordered the service to be done. The Plan denied your request. 
The Plan says the enrollee quit smoking greater than 15 years ago; therefore, the LDCT is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.  
 We reviewed the file and the Medicare rules. We find that the enrollee is not a current smoker and 
documentation shows the enrollee did not quit smoking within the last 15 years. Therefore, we decided that the 
Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that the OON provider is one of the few who can 
perform the procedure you say you need. The Plan denied your request. The Plan says you must receive your 
care from a network 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 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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT), of the abdomen; without contrast 
material, followed by contrast material(s) (74170). 
 
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan 
denied your request. The Plan says that you do not meet criteria for coverage of the requested service. 
 
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 this service. Our reviewer says that this 
service is medically necessary. Our physician reviewer found that a non-specific splenic lesion, 2.2 cm in 
diameter was found on a computed tomographic angiography (CTA) scan of the chest on July 1, 2022 and a six 
month follow-up was recommended. There is no history of a complete abdominal CT scan in the records. 
Splenic lesions may be seen in malignant and non-malignant instances. The spleen should be evaluated both 
before and following contrast administration to see the enhancement characteristics. Such evaluation is 
indicated and the requested CT scan should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this service have been met. Therefore, we decided that the Plan has to pre-
approve computed tomography (CT), of the abdomen; without contrast material, followed by contrast 
material(s) (74170).  
 
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 pre-approve additional one-way trips. 
 
You asked the Plan to pre-approve additional one-way trips. You say that you have a lot of health issues and 
surgeries this year and your multiple sclerosis (MS) has been very active. You also say you still have neurology 
appointments. The Plan denied your request. The Plan says the EOC clearly states 30 one-way trips per 
calendar year. The Plan also says that the 31st and beyond is not a covered benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 30 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional one-way trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve evaluation and extraction of tooth #2 performed by an 
oral surgeon. 
 
You asked the Plan to pre-approve dental services. You say that you were told an oral surgeon needs to do the 
tooth extraction. The Plan denied your request. The Plan says the service is covered but restrictions apply. 
 
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. This benefit includes limited 
oral exam-problem focused exam  two exams per year and extraction of tooth  one procedure per year when 
performed by a participating general dentist. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are 
covered only when performed by a participating general dentist. These services are not covered when 
performed by an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve evaluation  
and extraction of tooth #2 performed by an oral surgeon.
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 meet criteria for IRF care. The Plan denied your 
request. The Plan says the denial of authorization for IRF care is correct. 
 
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 your nursing, medical, and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may need physical and/or occupational therapy, there is no documented 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of postmenopausal osteoporosis and has previously tried alendronate. The 
documentation does not support that the enrollee has tried and failed zoledronic acid. The documentation does 
not support that zoledronic acid would likely be less effective and/or likely have adverse effects for the 
enrollee. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the bridge attachments (D6950). 
 
You asked the Plan to pre-approve the dental services. You say that the dental procedures are necessary for 
your dental implants. The Plan denied your request. The Plan says that your benefit for the requested item or 
service has already been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pre-approve the bridge attachments (D6950).  
 
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 pre-approve a clinical crown lengthening of hard tissue (D4249). 
 
You asked the Plan to pre-approve a clinical crown lengthening of hard tissue (D4249). You say that are 
appealing with supporting records. The Plan denied your request. The Plan says this service is not covered 
under the members benefit package. 
 
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 
clinical crown lengthening of hard tissue (D4249).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Bacillus Calmette-Guerin (BCG) live intravesical 
instillation.  
You asked the Plan to pre-approve BCG live intravesical instillation. You say that this will help treat the 
enrollee's condition. The Plan denied your request. The Plan says this is associated with a clinical trial that the 
enrollee is enrolled in, so the Plan is not responsible for coverage. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve BCG live intravesical instillation as part of a clinical trial. The 
Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan 
does not have to pre-approve Bacillus Calmette-Guerin (BCG) live intravesical instillation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for debride tissue/muscle - outpatient 
procedure provided on July 11, 2022. 
 
You asked the Plan to waive the copayment for debride tissue/muscle - outpatient procedure. You say that you 
thought this was an office visit. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
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 $100 
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
You have been asked to pay $100 copayment for debride tissue/muscle - outpatient procedure. This 
item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities and 
ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for debride 
tissue/muscle - outpatient procedure provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown tooth 
#30 (D6065). 
 
You asked the Plan to pre-approve the implant supported porcelain/ceramic crown (D6065).. You say that the 
service is medically necessary. The Plan denied your request. The Plan says this service is not covered under 
the benefit package. 
 
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 an 
implant supported porcelain/ceramic crown tooth #30 (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implant supported porcelain/ceramic crown tooth #'s 
10 and 11 (D6065) and custom fabricated abutment  includes placement tooth #'s 10 and 21 (D6057). 
 
You asked the Plan to pre-approve the implant supported porcelain/ceramic crown tooth #'s 10 and 11 (D6065) 
and custom fabricated abutment  includes placement tooth #'s 10 and 21 (D6057). The Plan denied your 
request. The Plan says these services are not covered under the benefit package. 
 
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 an 
implant supported porcelain/ceramic crown tooth #'s 10 and 11 (D6065) and custom fabricated abutment  
includes placement tooth #'s 10 and 21 (D6057).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve intravenous (IV) valproic acid. 
 
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 that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the Medicare-approved drug compendia 
contain an off-label citation for the use of IV valproic acid to treat migraine headaches. This is a medically-
accepted indication for the requested drug and the services are reasonable and medically necessary 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve intravenous (IV) valproic acid.  
 
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.