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

 
We decided that the Plan does not have to pre-approve a pontic - porcelain fused to predominantly base metal 
(D6241) for tooth number 20. 
 
You asked the Plan to pre-approve a pontic - porcelain fused to predominantly base metal (D6241) for tooth 
number 20. You say that your tooth is going to be empty, and you cannot chew. The Plan denied your request. 
The Plan says bridges are covered to replace only one upper anterior tooth or only two adjacent lower anterior 
teeth. There cannot be any missing posterior teeth in the arch. 
 
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. The Plan covers a pontic - 
porcelain fused to predominantly base metal (D6241) for tooth number 20 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 a pontic - porcelain fused to 
predominantly base metal (D6241) for tooth number 20. Our reviewer says that given the Plan criteria, the 
criteria for a bridge, even if it were a viable treatment plan, would not be met. Our physician reviewer found 
the recommended conditions for the service of the cantilevered pontic have not been specified in the treatment 
plan. Our physician reviewer also found, however, that an implant restoration to replace the posterior missing 
teeth would be a far superior treatment plan as it is much more stable for replacing posterior teeth with 
adequate strength. 
 
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 a pontic - porcelain fused to predominantly base metal (D6241) for tooth 
number 20 have not been met. Therefore, we decided that the Plan does not have to pre-approve a pontic - 
porcelain fused to predominantly base metal (D6241) for tooth number 20.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orgovyx tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that you are appealing this denial. The Plan 
denied your request. The Plan says this drug is not covered by Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Orgovyx tablets.  
 
Benefits for self-administered drug 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the IRF is the most appropriate discharge disposition 
for the enrollee, given their prior active lifestyle and continued acute and chronic medical needs. The Plan 
denied your request. The Plan says based on Medicare guidelines, the IRF services you are requesting do not 
meet the requirements for approval. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you are in the hospital and need to have 
rehabilitation because you cannot walk. The Plan denied your request. The Plan says the needed physical 
therapy and occupational therapy can be provided at a lower level of care, such as a skilled nursing level of 
care. 
 
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 do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
weakness and urinary tract infection. Medical problems are stable. There are no complex nursing or 
rehabilitation needs. While the medical records support a need for physical and/or occupational therapy, there 
is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that you would 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 IRF admission and services.
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF admission 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 that you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While you may have a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to waive the deductible for the walking boot. We decided that the Plan does not 
have to waive the deductible for the foot x-rays and the podiatry office visit. You asked the Plan to waive the 
deductible for the walking boot, the foot x-rays, and the podiatry office visit provided on October 24, 2022. 
You say that you don't agree with the cost-sharing. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to waive the deductible for the walking boot.  
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that the deductible does not apply to some services, even if your deductible has not 
been met.  The deductible does not apply to durable medical equipment. Your contract with the Plan also says 
that there is a $0 copayment for durable medical equipment. The Plan says you must pay a $303.55 deductible 
for the durable medical equipment. Based on the Plan contract, however, you cannot be asked to pay more than 
$0 for durable medical equipment. Therefore, we decided that the Plan has to waive the deductible for the 
walking boot.  
 
We also decided that the Plan does not have to waive the deductible for the foot x-rays and the podiatry 
office visit. 
 
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 also clearly states that there is a $750 
deductible that applies to services including outpatient diagnostic tests and therapeutic services and supplies 
and non-routine podiatry services.  
 
You have been asked to pay a $33.79 deductible for the foot x-rays. This item/service falls within the 
outpatient diagnostic tests and therapeutic services and supplies benefit category. You have also been asked to 
pay a $125.70 deductible for the podiatry office visit. This item/service falls within the podiatry services 
benefit category. You have been asked to pay a total deductible of $159.49 for the foot x-rays and the podiatry 
office visit because your deductible had not been met at the time these services were rendered. 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 deductible for the foot x-rays and the podiatry office visit.   
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve hepatobiliary system imaging (codes 78226 and 78227). 
 
You asked the Plan to pre-approve hepatobiliary system imaging. The Plan denied your request. The Plan says 
that this test is needed for certain liver and gallbladder problems when ultrasound results were unclear. The 
Plan also says the provided notes do not show that the enrollee had an ultrasound. 
 
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 hepatobiliary system imaging. Our 
reviewer says that the requested items/services are considered medically reasonable and necessary in this case. 
Our physician reviewer found the enrollee has chronic right upper quadrant pain and multiple food 
intolerances. The enrollee had a computed tomography of the abdomen dated September 25, 2022, which 
showed gall stones but no secondary sign of cholecystitis such as gall bladder wall thickening or 
pericholecystic fluid. Our reviewer found that the requested hepatobiliary iminodiacetic acid (HIDA) scan will 
show whether the cystic duct is patent hence evaluate for cholecystitis. The pharmacologic challenge is 
designed to determine if the enrollee's symptoms are reproducible with fatty food challenge. Our physician 
reviewer also found that based upon the history and the documented gallstones and the uncertain etiology of the 
enrollee's symptoms, the requested exams 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 hepatobiliary system imaging have been met. Therefore, we decided that the 
Plan has to pre-approve hepatobiliary system imaging (codes 78226 and 78227).  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy with image guided radiation 
therapy (77387, 77525, G6002). 
 
You asked the Plan to pre-approve proton beam therapy with image guided radiation therapy. You say that you 
want the Plan to approve the services. The Plan denied your request. The Plan says the services are not 
medically necessary. 
 
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 proton beam therapy with image guided 
radiation therapy. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found treatment guidelines do not consider proton therapy 
for prostate cancer to be experimental; however, any potential benefit or detriment of proton therapy over 
standard intensity-modulated radiation therapy (IMRT) is an investigational question being pursue by clinical 
trials. IMRT with or without image-guide radiation therapy (IGRT) are also highly effective and well tolerated. 
To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than 
IMRT/IGRT. The generally accepted standard of care for prostate cancer is to only offer proton beam therapy 
on clinical trials, and to not routinely offer it to patients. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy with image guided radiation therapy have not been met. 
Therefore, we decided that the Plan does not have to pre-approve proton beam therapy with image guided 
radiation therapy (77387, 77525, G6002).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Motegrity tablets. 
 
You asked the Plan to pre-approve Motegrity tablets. The Plan denied your request. The Plan says self-
administered medication does not fall under Part B coverage. 
 
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 Motegrity tablets.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the medical records provided support the need for 
the IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines the inpatient 
rehabilitation facility services you are requesting do not meet the requirements for approval. 
 
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 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. 
 
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 IRF admission and services.
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 you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the requested IRF 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 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 that 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 may have a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 IRF admission and services.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to further pay for the outpatient surgery services provided on July 20, 2022. 
 
You asked the Plan to further pay for the services provided. You say that you were informed the services would 
be covered in full. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $300 copay for each Medicare-covered outpatient surgical 
service in an outpatient hospital for outpatient surgery.  
 
The file shows that you received outpatient surgery services from an in-network provider. The Plan says you 
must pay a 50% coinsurance for the services provided. Based on the Plan contract, however, you cannot be 
asked to pay more than a $300 copay for outpatient surgical services in an outpatient hospital. The services fall 
within the outpatient surgery benefit category. Therefore, we decided that the Plan has to further pay for the 
outpatient surgery services provided on July 20, 2022.  
 
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: 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 you would regain more function with IRF services, 
compared to a lower level of care. The Plan denied your request. The Plan says the request 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 that your medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous injection of allogenic cellular/tissue-based 
product (VIA DISC procedure). 
 
You asked the Plan to pre-approve VIA DISC procedure. You say that this is appropriately indicated for the 
enrollee. The Plan denied your request. The Plan says there is little evidence in the literature to suggest that this 
is appropriate. 
 
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 VIA DISC procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/investigational therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of VIA DISC procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve percutaneous injection of allogenic cellular/tissue-based product (VIA DISC 
procedure).