Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 therapeutic continuous glucose 
monitor (CGM), and supplies. 
 
You asked the Plan to pre-approve the CGM and supplies. You say that the enrollee would benefit from a 
CGM. The Plan denied your request. The Plan says the enrollee does not require insulin three or more times 
daily. 
 
 
 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM and supplies. have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
FreeStyle Libre 2 therapeutic continuous glucose monitor (CGM), and supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to noble metal tooth 
#10 (D6752). 
 
You asked the Plan to pre-approve the dental services. You say that you do not agree with the decision. The 
Plan denied your request. The Plan says your benefit for the requested item or service has already been 
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. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows that the Plan approved the requested services up to your benefit limit at the time of the initial request. 
Therefore, we decided that the Plan does not have to pre-approve a retainer crown - porcelain fused to noble 
metal tooth #10 (D6752).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maintenance therapy with Keytruda (pembrolizumab) 
and Zirabev (bevacizumab-bvrz). 
 
You asked the Plan to pre-approve the requested combination maintenance therapy. You say that there is 
sufficient evidence to support this treatment. The Plan denied your request. The Plan says there is no literature 
supporting this maintenance regimen. 
 
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 the requested combination maintenance 
therapy. Our reviewer says that the requested maintenace therapy regimen is not medically reasonable and necessary. Our physician reviewer found the enrollee has stage IV uterine serous cell carcinoma that is HER2 
negative. She has been treated with carboplatin, Taxol, and bevacizumab. The requested maintenance therapy 
is not FDA-approved for the enrollee's condition. It is also not supported by one of the major drug compendia 
or by clinical research that appears in a CMS-approved medical journal, as there is no phase 3 data available 
for this regimen. 
 
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 combination maintenance therapy have not been met. Therefore, 
we decided that the Plan does not have to pre-approve maintenance therapy with Keytruda (pembrolizumab) 
and Zirabev (bevacizumab-bvrz).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a knee orthosis (code L1832). 
 
You asked the Plan to pre-approve a knee orthosis. You say that you disagree with this denial. The Plan denied 
your request. The Plan says the patient does not meet criteria for this item. 
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis with adjustable knee joints (L1832, 
L1833) is only covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s).  
 
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 knee orthosis. Our reviewer says that 
the requested knee orthosis is not medically necessary in accordance with Medicare rules. Our physician 
reviewer found the patient has osteoarthritis.  However, she has had no recent surgery or injury and has no 
instability.  As a result, she does not meet coverage criteria for this item. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a knee orthosis (code L1832).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neck surgery to be provided at an out-of-network 
(OON) facility. 
 
You asked the Plan to pre-approve the OON surgery. You say that you have seen this surgeon for various 
surgeries over the past seven years.  You said that this surgeon no longer practices at Plan facilities, and you 
don't want to have to change doctors to get this surgery. The Plan denied your request. The Plan says services 
with out-of-network providers and facilities are not covered. There are in-network providers and in-network 
facilities available that can provide the surgery you need. 
 
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 
neck surgery to be provided at an out-of-network (OON) facility.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan supartz visco-3 dose. 
 
You asked the Plan to pre-approve Hyalgan supartz visco-3 dose. You say that the services are necessary. The 
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage 
criteria have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that purified natural hyaluronates have been approved by 
the FDA for the treatment of symptomatic osteoarthritis of the knee in patients who have failed to respond to 
simple analgesics or conservative nonpharmacologic therapy. 
 
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 Hyalgan supartz visco-3 dose. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the plan requires a 3-
month trial of physical therapy be documented. This has not been accomplished and therefore, the request is 
deemed, at this time, not 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 Hyalgan supartz visco-3 dose have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Hyalgan supartz visco-3 dose.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Copaxone. 
 
You asked the Plan to pre-approve the Copaxone. You say that this drug is medically necessary. The Plan 
denied your request. The Plan says this drug is on the self-administered drug list and is excluded from coverage 
under 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 the Copaxone.
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 enrollee currently meets LTAC 
admission criteria under Medicare guidelines. The Plan denied your request. The Plan says the LTACH is not 
medically necessary, and the enrollee's needs can be met in a different setting, such as a hospital setting. 
 
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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with traumatic rib fractures, pneumothorax and developed 
acute hypoxic respiratory failure requiring intubation. The record indicates that the enrollee has ongoing acute 
medical issues and still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on November 9, 2022. 
 
You asked the Plan to pay for self-administered drugs. You say that you were unaware that you were given 
insulin as you have never taken it before. The Plan denied your request. The Plan says self-administered drugs 
do 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 pay for self-administered drugs provided 
on November 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM), 
supplies and accessories. 
 
You asked the Plan to pre-approve the CGM, supplies and accessories. You say that this device will better your 
condition. The Plan denied your request. The Plan says you do not require insulin three or more times daily. 
 
 
 
 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 use insulin with at least 
three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM, 
supplies and accessories. have not been met. Therefore, we decided that the Plan does not have to pre-approve 
a therapeutic continuous glucose monitor (CGM), supplies and accessories.
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 enrollee is a recent amputee and 
needs advance wound care. The Plan denied your request. The Plan says the LTACH is not medically 
necessary, and the enrollee's needs can be met at a lower level of care, such as a skilled nursing facility. 
 
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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted with lower extremity ulcers in the setting of peripheral 
vascular disease and required operative intervention. The record indicates that the enrollee has ongoing acute 
medical issues and still requires acute care services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and these have not been denied.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
   
You asked the Plan to pre-approve SNF care. You say that you have not been able to participate in the therapy 
sessions at the facility where you are now. You say that you need a SNF level of care because you need therapy 
and medical attention. The Plan denied your request. The Plan says a SNF admission is not medically 
necessary, and your needs can be met at a lower level of care. 
 
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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires acute rehab to 
maximize their progress. The Plan denied your request. The Plan says an LTACH admission is not medically 
necessary, and the enrollee's needs can be met in the current hospital setting. 
 
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 care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee is improving and requires short-term additional acute care hospital 
services that can be safely provided at the current facility. The enrollee does not require services at the LTACH 
that are not already available at the current facility.  
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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that the medical records provided support the need for 
the CGM. The Plan denied your request. The Plan says the enrollee does not require insulin three or more times 
daily. 
 
 
 
 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. You say that you appealed $50 for your electric bill, and 
you would like to know if it was approved by the Plan. The Plan denied your request. The Plan says the criteria 
for eligibility have not been met. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided from December 21, 
2022, through December 22, 2022. 
 
You asked the Plan to pay for the self-administered drugs. You say that the claim needs to be reprocessed. The 
Plan denied your request. The Plan says self-administered drugs do 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 pay for the self-administered drugs 
provided from December 21, 2022, through December 22, 2022.  
 
Benefits for the self-administered drugs 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 waive the copayments for the radiation treatments provided from 
June 16, 2022, to July 27, 2022. 
 
You asked the Plan to waive the copayments for the radiation treatments. You say that you were under the 
understanding that the computed tomography scan is done with the radiation treatment. 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 $60 
copayment for each Medicare-covered outpatient therapeutic radiology service.  
 
You have been asked to pay a $60 copayment for each the radiation treatment. These items/services fall 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 copayments for the radiation treatments provided from June 16, 2022, to July 27, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says that the enrollee does not meet criteria for this procedure. 
 
The Plan follows Medicare rules. Medicare rules state that facet joint injections may be covered under certain 
circumstances. 
 
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 facet joint injections. Our reviewer says 
that the enrollee meets criteria for these facet joint interventions. Our physician reviewer found the enrollee has 
mid back pain. On physical examination the enrollee has thoracic facet tenderness, decreased range of motion, 
and positive facet loading tests. The cervical spine abnormalities do not explain the thoracic pain and signs. 
The enrollee meets all of the criteria and this request 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 facet joint injections have been met. Therefore, we decided that the Plan has to 
pre-approve facet joint injections.  
 
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.