Persius/hicric huggingface dataset:
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 IRF care is medically necessary. The Plan denied 
your request. The Plan says authorization denied because the IRF care is not medically necessary, and your 
needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 your medical problems are stable, and there are no complex nursing or rehabilitation 
needs. You do not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While you have 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says services are 
available with in-network providers. 
 
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 dialysis services at issue in this appeal. We found no exception that would 
require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-
approve dialysis services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Humalog 100mg/ml vial. 
 
You asked the Plan to pre-approve the Humalog. You say that the drug is medically necessary. The Plan denied 
your request. The Plan says this drug is considered self-administered. 
 
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 the Humalog 100mg/ml 
vial.   
Benefits for the Humalog 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gemtesa. 
 
You asked the Plan to pre-approve Gemtesa. You say that the enrollee has tried and failed multiple 
anticholinergic medications. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the requested drug is not covered under 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 Gemtesa.  
 Benefits for Gemtesa 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor sensor. 
 
You asked the Plan to pre-approve Freestyle Libre sensor. You say that the requested item is a medical 
necessity for you. The Plan denied your request. The Plan says rules for coverage for continuous glucose 
monitors and related supplies have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least 
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing 
results. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre sensor have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre continuous 
glucose monitor sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Surgical Pathology Procedures provided on February 1, 2022 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Surgical Pathology Procedures. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and it was determined these services were not urgent or emergent. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for Surgical Pathology Procedures provided on 
February 1, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Omeprazole 40mg capsule. 
 
You asked the Plan to pre-approve the Omeprazole 40mg capsule. You say that the drug is medically 
necessary. The Plan denied your request. The Plan says your Medicare Advantage (MA) plan does not cover 
outpatient prescription 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 the Omeprazole 40mg 
capsule.  
 
Benefits for the Omeprazole 40mg capsule 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up (D2950) and crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that one type of crown is covered under your 
plan. You say that you feel that this one should be covered. You also say that there is no substantial difference 
between the covered crown and the one recommended by your dentist. The Plan denied your request. The Plan 
says the requested services are not listed as covered. 
 
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 core build up and crown 
are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve core build up (D2950) and crown (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a partial lower
denture (D5214).
You asked the Plan to pre-approve a complete upper denture and a partial lower denture. You say that the items
are necessary. The Plan denied your request. The Plan says the benefit 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 complete
upper dentures and partial lower dentures once every 96 months.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a complete upper denture and a partial lower denture have not been met. Specifically, you received
a complete upper denture and a lower partial denture on October 9, 2018. Therefore, we decided that the Plan
does not have to pre-approve a complete upper denture (D5110) and a partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of an impacted tooth, therapeutic drug injection,
evaluation for deep sedation/general anesthesia, first 15 minutes of general anesthesia, and additional 15
minutes of general anesthesia provided by an OON provider on November 4, 2019.
You asked the Plan to pay for the removal of an impacted tooth, therapeutic drug injection, evaluation for deep
sedation/general anesthesia, and anesthesia services. You say that you had jaw pain from an impacted,
fractured, and infected wisdom tooth. You also say that your regular dentist could not do the surgery and
referred you to this oral surgeon. The Plan denied your request. The Plan says neither your general dentist nor
the oral surgeon who provided these services are in-network plan providers.
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
covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for
the removal of an impacted tooth, therapeutic drug injection, evaluation for deep sedation/general anesthesia,
first 15 minutes of general anesthesia, and additional 15 minutes of general anesthesia provided by an OON
provider on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that you do not have transportation to 
your dialysis treatments. The Plan denied your request. The Plan says you have exhausted the established 
benefit of 24 one-way trips. 
 
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 24 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 non-emergency taxi transportation (A0100).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMS device. 
 
You asked the Plan to pre-approve the requested device. You say that real-world studies support the clinical 
benefit. The Plan denied your request. The Plan says the clinical value has not been demonstrated. 
 
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 the requested device. Our physician 
reviewer found that the device consists of a sensor device placed in the pulmonary artery to allow measurement 
of pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical 
study on which approval was based showed improved clinical outcomes and decreased hospitalizations in those 
in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection 
fraction and was somewhat limited in scope. Published expert opinion in the cardiology literature is supportive 
of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical 
studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. 
As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary 
in this enrollees clinical management. 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 device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMS device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection of a radioactive tracer
provided on December 14, 2020.
You asked the Plan to waive the copayment for the injection of a radioactive tracer. You say that this should be
a lab procedure instead of outpatient surgery. You say that a student did the procedure and you never saw a
doctor or nurse. The Plan denied your request. The Plan says you have been charged the correct cost sharing
amount.
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 $245
copayment for Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and
Ambulatory Surgical Centers.
You have been asked to pay a $245 copayment for the injection of a radioactive tracer. This procedure is
considered a surgical procedure. The injection of a radioactive tracer falls within the Outpatient Surgery and
Other Medical 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 the injection of a radioactive tracer provided on December 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoe insert orthosis (L5000).
You asked the Plan to pay for the shoe insert brace. You say that the claim should be paid. The Plan denied
your request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable
medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or
irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the
enrollee has received the same durable medical equipment on September 25, 2018. This orthosis is still within
the 5-year RUL and the documentation submitted does not show that the orthosis is irreparably worn, irreparably 
damaged, or that the enrollee had a change in medical condition to warrant the orthosis at issue.
Based on this information, we decided that Medicare rules for coverage of the shoe insert brace have not been
met. Therefore, we decided that the Plan does not have to pay for the shoe insert orthosis (L5000).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on November 
15, 2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that the lab work was performed 
as part of your wellness visit and should be covered in full. The Plan denied your request. The Plan says you 
have been charged the correct cost sharing amount. 
 
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 $10 copayment for laboratory tests. The Plan contract also says that there is a $0 copayment for an annual physical. 
The contract says that if you receive additional services then additional cost sharing may apply. 
 
The record shows this claim was approved, and you have a cost sharing amount. You have been asked to pay a 
$10 copayment for laboratory services. Laboratory services falls within the Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies 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 
laboratory services provided on November 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an UPwalker.
You asked the Plan to pre-approve the walker. You say that this is medically necessary. The Plan denied your
request. The Plan says the provider is not Medicare-certified.
The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are
enrolled in the Medicare program.
The rendering providers for this walker are not eligible to bill Medicare. The Plan did not pre-approve the
walker. 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 UPwalker.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an x-ray of the lumbar spine provided on 
November 6, 2021. 
 
You asked the Plan to waive the copayment for an x-ray. You say that it is not your fault you had to go to two 
different facilities to get your tests done. You also say that you should only have one copayment. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing amount. 
 
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 $60 
copayment for an x-ray. The contract also says that if you have multiple services performed by different 
providers, separate cost-sharing will apply. 
 The Plan confirmed that the two facilities are different providers, and a separate cost sharing amount applies. 
You have been asked to pay a $60 copayment for an x-ray. An x-ray falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 x-ray of the lumbar spine provided on November 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve high frequency chest wall oscillation device (HFCWOD) E0483. You say
that the out of network HFCWOD is better and has better features. The Plan denied your request. The Plan says
you must obtain care from an in network provider unless there is an emergency, you are out of area, or care
cannot be provided by an in 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
the medical services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency taxi transportation (A0100). 
 
You asked the Plan to pre-approve additional transportation. You say that the enrollee has depended on non-
emergent transport since its inception. You also say that the enrollee has said that it is difficult for a family 
member who assists him to transport him to the treatments that prolong his life. The Plan denied your request. 
The Plan says you have already exhausted the established benefit. The Plan also says that additional trips are 
non-covered services in accordance to the plan benefit package you selected. 
 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 thirty-six (36) (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 non-emergency taxi transportation (A0100).