Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (CPT code J1439). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug Venofer (iron 
sucrose). The Plan states there is no indication our preferred drug(s) would likely be: less effective, and/or 
cause adverse effects for the enrollee. 
 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 the medication. Our physician reviewer 
found the Plan requires a trial of drug Infed (iron dextran) and Venofer (iron sucrose), before they will approve 
the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no 
documentation provided indicating that the plans required drug(s) 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 the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer (CPT code J1439).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee has no support at home and 
intermittent confusion. You say that short term rehabilitation is necessary for the enrollee to maximize her 
potential and ensure safety. You say that the enrollee requires daily skilled care before returning home. The 
Plan denied your request. The Plan says SNF care is not medically necessary. 
 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, 
had stable vital signs, was treated for pain, and had intermittent confusion. The enrollee received physical 
therapy in the acute hospital. The enrollee was at a supervision to contact guard assist level for functional 
mobility, including gait to 75 feet with a rolling walker. There are no identifiable skilled nursing service needs. 
While there are identifiable skilled therapy service needs, they are not required on a daily basis. The enrollee 
does not meet the severity of illness or intensity of service criteria for 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive dental services received from September 1, 
2021, to October 20, 2021. 
 
You asked the Plan to pay for the comprehensive dental services. You say that these services were sepsis-
related for a dead tooth after receiving a vaccine. You believe this should be covered. The Plan denied your 
request. The Plan says you voluntarily disenrolled from the Optional Supplemental Benefit (OSB) for 
comprehensive dental services on June 3, 2021.  You did not re-enroll in the OSB until January 1, 2021.  All of 
the services you received in September and October of 2021 are only coverable under the OSB, not your 
standard dental coverage.  The Plan did pay for the preventive x-ray you had on September 1, 2021, under the 
standard dental benefit. 
 
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 the standard dental benefit (regardless of the reason for the services). You were not 
enrolled in the comprehensive dental benefit at the time of these services. Therefore, we decided that the Plan 
does not have to pay for comprehensive dental services received from September 1, 2021, to October 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee has not had long enough with 
physical therapy to gain strength. The Plan denied your request. The Plan says the enrollee does not need daily 
therapy or skilled nursing services. 
 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 services. Our physician reviewer 
found that the enrollee is at a supervision assist level for sitting up, bed to chair transfers, and toileting. She is 
independent for eating, setup for oral hygiene, and moderate assist for bathing. She does not have documented 
skilled nursing or skilled therapy needs. She appears to be functioning at or near her baseline. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
panoramic x-ray (D0330) provided on December 28, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the problem focused limited oral evaluation and panoramic x-ray. You say that 
prior to receiving these services you called and were told that this treating provider was in-network. The Plan 
denied your request. The Plan says the problem focused limited oral evaluation is not a covered expense under 
your dental plan. Services performed by an OON provider are not covered because your healthcare plan does 
not have OON benefits. The Plan also says that when you contacted the Plan you asked for the provider 
eligibility for another provider, not the provider you were treated by on this date of 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. Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluation (D0140) not among those covered under this benefit. The contract also says that you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) provided on December 28, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 24, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on July 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 2, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is bundled to another service billed on the same day by the same provider. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on November 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy. 
 
You asked the Plan to pre-approve hyperbaric oxygen therapy. You say that this is medically necessary. The 
Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is only covered when the 
enrollee has an indication as listed 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 hyperbaric oxygen therapy. Our 
reviewer says that the requested hyperbaric oxygen therapy is not medically reasonable and necessary. Our 
physician reviewer found the review indicates that the enrollee has a history of diabetes and chronic peripheral 
artery disease. The review has determined that the enrollee does not have a covered indication for the requested 
hyperbaric oxygen therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of hyperbaric oxygen therapy have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses (V2757) purchased on January 2, 2022. 
 
You asked the Plan to pay for the eyeglasses. You say that you do not understand why you have been 
reimbursed so little for these services since you are covered for $400 per year. The Plan denied your request. The Plan says you previously used $400 of your vision benefit on December 30, 2021. This benefit resets every 
12 months, so you had $100 remaining on the date in question. You have been reimbursed $100 for the 
eyeglass services provided on January 2, 2022, which exhausted your benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services up to $500 every 12 months. 
 
We looked at the file and the Plan's rules. The documentation shows that you used $400 of your benefit less 
than 12 months before the date in question, and the Plan paid the remaining $100 for these services. This means 
that you have used your full $500 routine eyeglasses benefit. Therefore, we decided that the Plan does not have 
to pay for the eyeglasses (V2757) purchased on January 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tertiary care services. 
 
You asked the Plan to pre-approve tertiary care services. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve tertiary care services. Our reviewer says 
that the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation requiring a tertiary care referral. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of tertiary care services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve tertiary care services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the fitness equipment purchased on 
November 26, 2021. 
 
You asked the Plan to provide reimbursement for the fitness equipment. You say that you received 
reimbursement for equipment before. You also feel that this should be covered since you should not go to a 
gym with COVID-19 in the community. The Plan denied your request. The Plan says this is not a Medicare-
covered item and is not covered by your Plan as a supplemental benefit. 
 The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The Plan offers a supplemental benefit for fitness services, but this does not include fitness 
equipment. 
 
Since the equipment is not primarily medical in nature and is not covered by a supplemental benefit of the Plan, 
neither Medicare nor your Plan provides coverage for this equipment.  
 
 Therefore, we decided that the Plan does not have to provide reimbursement for the fitness equipment 
purchased on November 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs modern rehab. The Plan 
denied your request. The Plan says the enrollee does not require daily skilled services on an inpatient basis. 
 
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 services. Our physician reviewer 
found that the enrollee is at an independent assist level for rolling and sitting up, supervision for standing and 
walking, and minimal assist for transfers. She does not have documented skilled nursing or skilled therapy 
needs.  Daily skilled services are not shown to be required to establish a maintenance program or to prevent 
deterioration of the enrollees condition. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified fixed prosthodontic procedure (D6999) 
provided on January 4, 2022. 
 
You asked the Plan to pay for the unspecified fixed prosthodontic procedure. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says this is not covered 
under your dental benefit. 
 
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 the 
unspecified fixed prosthodontic procedure (D6999) provided on January 4, 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 enrollee continues to require strengthening, 
functional mobility training, self-care training, and transfer training, balance training, endurance and gait 
training, pain management and safety education and training. The Plan denied your request. The Plan says the 
requested admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the provided documentation does not indicate that the enrollee has complex 
nursing or rehabilitation needs. The reviewer found that the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. The reviewer 
also found there is not a reasonable expectation that this patient will be able to fully participate in and benefit 
from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve 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 medial branch block injection services. 
 
You asked the Plan to pre-approve medial branch block injection services. You say that this procedure is 
medically reasonable and necessary. The Plan denied your request. The Plan says information that was 
necessary to make a decision regarding whether the coverage criteria is satisfied was not returned. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of medial branch block injection services. 
have been met. Specifically, no documentation was returned to the Plan regarding the level of pain relief the 
enrollee received from the most recent injections. Therefore, we decided that the Plan does not have to pre-
approve medial branch block injection services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary. 
The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 Vertiflex procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex procedure is experimental. More research is needed. 
 
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care (99233), chest x-ray (71045), 
subsequent nursing facility care (99308), doppler echocardiography (93321), and doppler echocardiography 
color flow velocity mapping (93325) provided on May 13, 2021. 
 
You asked the Plan to pay for the evaluation and management services. You say that the services were 
medically necessary. The Plan denied your request. The Plan says the enrollees claim would be covered under 
Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the 
last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on May 10, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care 
(99233), chest x-ray (71045), subsequent nursing facility care (99308), doppler echocardiography (93321), and 
doppler echocardiography color flow velocity mapping (93325) provided on May 13, 2021.