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

 
We decided that the Plan has to pay for the limited oral evaluation (D0140), the first intraoral periapical x-ray 
(D0220), each additional intraoral periapical x-ray (D0230), the periodic exam (D0120), the panoramic x-ray 
(D0330), and the prophylaxis (D1110) provided by an out-of-network provider from December 15, 2021, to 
February 9, 2022. 
 
You asked the Plan to pay for the limited oral evaluation (D0140), the first intraoral periapical x-ray (D0220), 
each additional intraoral periapical x-ray (D0230), the periodic exam (D0120), the panoramic x-ray (D0330), 
and the prophylaxis (D1110). You say that the claims should be paid at 100% for in-network and out-of-
network providers. The Plan denied your request. The Plan says that the claims were processed correctly. 
 
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 the 2021 Evidence of Coverage and submitted an 
incorrect 2022 Evidence of Coverage. This means we cannot determine if the Plan's denial of dental services is 
supported. Therefore, we decided that the Plan has to pay for the limited oral evaluation (D0140), the first 
intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), the periodic exam 
(D0120), the panoramic x-ray (D0330), and the prophylaxis (D1110) provided by an out-of-network provider 
from December 15, 2021, to February 9, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and treatment 
of a root canal obstruction; non-surgical access (D3331) provided by an endodontist. 
 
You asked the Plan to pre-approve a comprehensive oral evaluation and treatment of a root canal obstruction. 
You say that you are in pain and your dentist told you that you need to see an endodontist because you have a 
cardiac problem and are taking Eliquis. The Plan denied your request. The Plan says the supplemental dental 
services benefit of your contract only provides coverage for dental services that are performed by a 
participating general dentist. Dental services by an endodontist are not covered, and there is no listed benefit 
for root canals. 
 
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. Specifically, dental services must be performed by a participating 
general dentist. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral 
evaluation (D0150) and treatment of a root canal obstruction; non-surgical access (D3331) provided by an 
endodontist.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 
You asked the Plan to pre-approve Evenity. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Evenity. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a trial of Prolia 
or Reclast before they will approve the requested drug. In this case, the patient has not tried and failed the 
required drugs. There is no documentation provided indicating that the plans required drugs 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral - complete series of radiographic images 
(D0210) provided March 30, 2022. 
 
You asked the Plan to pay for the complete series of x-rays. You say that you would like this covered. The Plan 
denied your request. The Plan says you have exceeded the frequency limit for this service. 
 
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. The Plan covers the complete 
series of x-rays once every 36 months. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a complete series of 
x-rays was previously covered on March 3, 2021. Based on this information, we decided that the Plan's 
frequency limit for coverage of the complete series of x-rays has been exceeded. Therefore, we decided that the 
Plan does not have to pay for the intraoral - complete series of radiographic images (D0210) provided March 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on March 17, 2022. 
 
You asked the Plan to pay for a partial denture. You say that you were told the services would be covered at 
100%. The Plan denied your request. The Plan says that this service is covered by the Plan's dental benefit; 
however, your benefit for one denture (D5214) every five years has been exhausted. 
 
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. The Plan covers one partial 
denture (D5214) every five years. 
 
We looked at this case file, the Plan's rules, and Medicare rules. The record shows the Plan paid for a partial 
denial (D5214) provided on August 6, 2020; therefore, the benefit for partial dentures has been exhausted. 
Therefore, we decided that the Plan does not have to pay for a mandibular partial denture (D5214) provided on 
March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
February 16, 2022. 
 
You asked the Plan to pay for dental services. You say that you have been going to this dentist since 2016. The 
Plan denied your request. The Plan says the rendering dentist is out-of-network. 
 
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 covered 
dental services when the services are a participating provider.  
 
We looked at the file and Medicare rules. The rendering dentist is out-of-network. Based on this information, 
we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that 
the Plan does not have to pay for dental services provided by an out-of-network provider on February 16, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
You asked the Plan to pre-approve the SNF admission. You say that you would like the enrollee to be allowed 
admission to the SNF to help reach their maximum function. The Plan denied your request. The Plan says the 
enrollee does not meet the health condition for this stay. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 the SNF admission. Our reviewer says 
that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee 
does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a 
skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized 
skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled 
nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve medial branch blocks. 
 
You asked the Plan to pre-approve medial branch blocks. You say that the requested medial branch blocks are 
medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for 
the requested medial branch blocks. 
 
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 medial branch blocks. Our reviewer 
says that the requested medial branch blocks are medically necessary. Our physician reviewer found the 
enrollee has lumbar facet disease and had Right L4/L5 and L5/S1 diagnostic medial branch blocks (MBBs) 
performed on May 31, 2022. The request was for repeat diagnostic blocks. The Plan denied the request stating 
it did not meet the 2-week requirement. The requirement is for 14 days between diagnostic injections. This 
meets that requirement.  The procedure is medically reasonable and 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 medial branch blocks have been met. Therefore, we decided that the Plan has to 
pre-approve medial branch blocks.  
 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 pay for the bitewing x-ray (D0274), and periapical x-rays (D0220, 
D0230 x 3) provided on February 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that you cannot hear. You say that you went to the 
dentist with a chipped tooth. You say that at no point did anyone tell you what they were doing for your 
approval. You say you feel you were taken advantage of. You also say that you feel you do not owe this 
money. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 and 1 set of bitewings and 1 periapical 
x-ray are covered per calendar year, the frequency limits have been exceeded. The record shows that the Plan 
paid for a set of bitewing x-rays and a periapical x-ray that you received on February 15, 2022. Therefore, we 
decided that the Plan does not have to pay for the bitewing x-ray (D0274), and periapical x-rays (D0220, 
D0230 x 3) provided on February 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided by a 
participating provider on February 10, 2022. 
 
You asked the Plan to pay for a comprehensive oral evaluation. You say that you went for a second opinion. 
The Plan denied your request. The Plan says the benefit limit for D0150 has already been met and exhausted. 
 
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 one 
comprehensive oral evaluation every three years.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D0150 was provided on 
February 7, 2022. Based on this information, we decided that the Plan's rules for coverage of a comprehensive 
oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a 
comprehensive oral evaluation (D0150) provided by a participating provider on February 10, 2022.
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 the requested LTACH admission is 
medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not 
medically necessary. 
 
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 admission is not medically necessary. Our physician reviewer found the enrollee 
was admitted with head and neck cancer and required extensive operation. The record indicates that the 
enrollee requires additional acute care services, including further operative intervention. The enrollee continues 
to receive acute care services, and these have not been denied. The medical record does not indicate that the 
enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 
The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued care with an out-of-network specialist. 
 
You asked the Plan to pre-approve continued care with an out-of-network specialist. You say that the requested 
continued care with the out-of-network specialist is medically necessary. The Plan denied your request. The 
Plan says the requested continued care with the out-of-network specialist is not medically necessary. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 continued care with an out-of-network 
specialist. Our reviewer says that the requested continued care with the out-of-network specialist is not 
medically necessary. Our physician reviewer found the record indicates that the enrollee has a history of breast 
cancer with ipsilateral upper extremity lymphedema. The record indicates the requested visit is for routine care 
and does not indicate the performance of active treatment as defined by Medicare rules. The pan has indicated 
that an in-network provider is available to provide the required services. The elements of the coverage criteria 
are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued care with an out-of-network specialist have not been met. Therefore, 
we decided that the Plan does not have to pre-approve continued care with an out-of-network specialist.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The 
Plan denied your request. The Plan says that the requested Keytruda is not medically necessary. 
 
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 Keytruda is medically necessary. Our physician reviewer found the enrollee was treated in past with 
carbo/alimta/keytruda followed by alimta/keytruda maintenance through 2020 now with recurrence. As this 
enrollee has never failed carbo/alimta/keytruda, I deem this a recommencement of first line therapy and 
approve per National Comprehensive Cancer Network (NCCN) compendia. 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda.  
 
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 pay for a limited oral evaluation (D0140), cone beam imaging 
(D0367), and bone replacement graft (D7953) provided on February 14, 2022. 
 
You asked the Plan to pay for an evaluation, imaging, and replacement graft. You say that you thought these 
services were covered. The Plan denied your request. The Plan says a limited oral evaluation (D0140), cone 
beam imaging (D0367), and bone replacement graft (D7953) are not covered by your Plan's dental benefits. 
 
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 a limited 
oral evaluation (D0140), cone beam imaging (D0367), and bone replacement graft (D7953) provided on 
February 14, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the 
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an 
interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure and coronary artery disease and had coronary artery bypass grafting. Medical problems are stable. There are no 
complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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.