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

 
We decided that the Plan has to pre-approve use of Ruxience. 
 
You asked the Plan to pre-approve Ruxience. You say that you are appealing this denial. The Plan denied your 
request. The Plan says that this is not medically necessary. 
 
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. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit medical records for review, nor did the Plan submit 
documentation of reasonable attempts to obtain medical records. We requested medical records but none were 
submitted to us. Without medical records, we cannot determine whether Ruxience is medically reasonable and 
necessary for the enrollee at this time. Therefore, the Plan has not shown that its decision to deny authorization 
for this drug is medically correct or justified according to Medicare rules. Therefore, we decided that the Plan 
has to pre-approve use of Ruxience.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on October 10, 2022. 
 
You asked the Plan to waive the copayment for office visit. You say that you believe you do not owe a 
copayment for this 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 a $40 
copayment for physician/practitioner services, including doctors office visitp. 
 
You have been asked to pay a $40 copayment for office visit. This item/service falls within the 
physician/practitioner services, including doctors office visitp 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 office visit provided on October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve occlusal guard (D9944). 
 
You asked the Plan to pre-approve occlusal guard. You say that this is medically necessary. The Plan denied 
your request. The Plan says that there is a lack of evidence to prove the enrollee grinds their teeth (Bruxism) 
and/or have jaw hinge symptoms. 
 
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 occlusal 
guard 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 occlusal guard. Our reviewer says that 
this is medically necessary. Our physician reviewer that the enrollee presents with jaw soreness and occlusal 
wear which indicates bruxism. It is medically reasonable and necessary to provide an occlusal guard to 
alleviate the symptoms and to protect the teeth from ongoing wear and trauma.   
 
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 occlusal guard have been met. Therefore, we decided that the Plan has to pre-
approve occlusal guard (D9944).  
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
October 14, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you disagree with the 
copaymet. 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 a $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for emergency room services. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency room services 
provided on October 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a medical eye examination (92004) and a 
corneal pachymetry (76154) provided on October 3, 2022. 
 
You asked the Plan to reduce the copayment for a medical eye examination (92004) and a corneal pachymetry 
(76154). You say that your copayment is only $20 per visit. You also say your balance should only be $10. 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 a $20 
copayment for each Medicare-covered examination to diagnose and treat diseases of the eyes.  
 
 You have been asked to pay a $20 copayment for a medical eye examination (92004). You have also been 
asked to pay $12.68, which is less than the $20 copayment for a corneal pachymetry (76154). This item/service 
falls within the Medicare-covered examination to diagnose and treat diseases of the eyes 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 reduce the copayment for a medical eye examination (92004) and a corneal 
pachymetry (76154) provided on October 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Mounjaro. 
 
You asked the Plan to pre-approve Mounjaro. You say that you are diabetic and also struggling with weight 
loss. The Plan denied your request. The Plan says Medicare Part B is not responsible for self-administered 
drugs. 
 
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 Mounjaro.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each speech therapy visit provided on 
September 30, 2022, to November 15, 2022. 
 
You asked the Plan to waive the copayment for each speech therapy visit. You say that your vocal cords were 
damaged during an operation and should be covered by the Plan. 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 a $40 
copayment for outpatient rehabilitation service. 
 
You have been asked to pay a $40 copayment for each speech therapy visit. This item/service falls within the 
outpatient rehabilitation service 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. The total you owe is $160 ($40 per visit x 4 visits = $160). Therefore, we 
decided that the Plan does not have to waive the copayment for each speech therapy visit provided on 
September 30, 2022, to November 15, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on August 14, 2022. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
were injured at the hospital in the bathroom, they should be paying this copayment. 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 a $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an in-network emergency room (ER) visit. This item/service 
falls within the emergency care benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an in-network emergency room (ER) visit provided on August 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will not get the care she needs if she is 
moved to another facility. 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 complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an IRF stay.  The enrollee's medical status does not require intensive physician and nursing oversight in an IRF. While the 
enrollee may have a need for additional multiple therapies, including physical therapy and occupational 
therapy, the documentation does not reveal that the enrollee requires this therapy on an intensive IRF level. 
 
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 an IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an magnetic resonance imaging (MRI) 
provided on September 30, 2022. 
 
You asked the Plan to waive the copayment for an magnetic resonance imaging (MRI). You say that you 
disagree with the copaymet. 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 a $170 
copayment for outpatient diagnostic testsMedicare-covered radiological diagnostic services, not including 
Xrays. 
 
You have been asked to pay a $170 copayment for an magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic testsMedicare-covered radiological diagnostic services, not including 
Xrays 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 an magnetic resonance imaging 
(MRI) provided on September 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Fluorodeoxyglucose (FDG) Positron Emission 
Tomography (PET) scan. 
 
You asked the Plan to pre-approve the requested testing. The Plan denied your request. The Plan says the 
requested use of the testing is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 the requested testing. Our physician 
reviewer found that the enrollee had a previous PET-CT scan in March of 2022, which did not show 
hypermetabolic disease. There is no strong suspicion of malignancy. Therefore, a repeat imaging is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested testing have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen services (E0439 and E0434), provided on 
September 1, 2022. 
 
You asked the Plan to pay for the oxygen services. You say that the items should be covered. The Plan denied 
your request. The Plan says this benefit is excluded under the plan benefits when an Enrollee resides in a 
certified Medicare Skilled Nursing Facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the oxygen services were used in a SNF or hospital. Therefore, we decided that the Plan 
does not have to pay for the oxygen services (E0439 and E0434), provided on September 1, 2022.
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 enrollee currently meets full IRF criteria and 
admission is medically necessary. The Plan denied your request. The Plan says the enrollee's ongoing skilled 
therapy and nursing needs can be provided at current facility or alternate lower 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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oncology (colorectal) screening (81528). 
 
You asked the Plan to pre-approve the colorectal screening. You say that the Cologuard test is recommended 
for you due to a family history of colon cancer and ongoing gastrointestinal issues. You also say that failure to 
allow this testing could be seen as gross medical negligence on a number of levels. The Plan denied your 
request. The Plan says this request is not medically necessary because the records show you have a family 
history of colorectal cancer, and you are not between ages 50 to 85. The Plan also says your medical record 
does not indicate whether you have any symptoms of colon cancer, such as blood in your stool. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. Medicare rules say that The Cologuard test is covered 
once every three years for Medicare beneficiaries that meet all of the criteria listed in the Medicare rules 
section of this letter. 
 
Specifically, the record shows that you are not between the ages of 50 and 85 years old. Therefore, we decided 
that the Plan does not have to pre-approve an oncology (colorectal) screening (81528).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that the service is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet the criteria for coverage 
 
The Plan follows Medicare rules. Medicare rules say that SBRT can be covered when specific criteria are met. 
 
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 SBRT. Our reviewer says that criteria 
are not met for coverage of the requested service. Our physician reviewer found SBRT is not covered when the 
tumor burden cannot be completed targeted with acceptable risks to critical normal tissues. In other words, in 
patients with widespread metastases, even if controlled, would not qualify under this LCD. The LCD also only 
SBRT medically necessary for pelvic tumors in the setting of prior radiation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve an electronic connection between wheelchair controller and two or 
more power seating system motors (E2311), harness for upgrade to expandable controller (E2313), and 
expandable controller (E2377). 
 
You asked the Plan to pre-approve an electronic connection, harness for upgrade to expandable controller, and 
expandable controller. The Plan denied your request. The Plan says that these accessories cannot be covered. 
The Plan also says although there are two approved power options on this wheelchair, there is not a medical 
need to control these power options through the joystick. 
 
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 an electronic connection, harness for 
upgrade to expandable controller, and expandable controller. Our reviewer says that the requested items are 
considered medically reasonable and necessary in this case. Our physician reviewer found the expandable 
controller with harness and electronic connection are necessary to operate the group 3 power wheelchair base, 
the power tilt and recline, and power elevating leg rests by a joystick. Our reviewer found that the enrollee 
requires a joystick to operate the manual wheelchair as well as the coordinated operation of the power 
components. Our physician reviewer also found that the expandable controller (E2377) with harness (E2313) 
and electronic connection (E2311) is 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 an electronic connection, harness for upgrade to expandable controller, and 
expandable controller have been met. Therefore, we decided that the Plan has to pre-approve an electronic 
connection between wheelchair controller and two or more power seating system motors (E2311), harness for 
upgrade to expandable controller (E2313), and expandable controller (E2377).  
 
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.