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

 
We decided that the Plan has to pre-approve dental services to be provided by a participating provider. 
 
You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the criteria for the dental services requested have not been met. 
 
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 has failed to provide the correct x-rays that were needed to render a 
decision. Therefore, we decided that the Plan has to pre-approve dental services to be provided by a 
participating provider. 
 
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 retainer crowns (D6752) for teeth #2, #4, #5, #6, #11, 
and #12, and pontic - porcelain fused to metal (D6242) for teeth #10, #13, #3, #7, #8, and #9 to be provided by 
a participating provider. 
 
You asked the Plan to pre-approve retainer crowns (D6752) and pontic - porcelain fused to metal. You say that 
you need this dental work done so you can eat properly. The Plan denied your request. The Plan says the 
criteria for D6752 and D6242 has not been met. 
 
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 retainer 
crowns (D6752) and pontic - porcelain fused to metal when the services are medically necessary and 
reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve retainer crowns (D6752) and pontic - 
porcelain fused to metal. Our reviewer says that D6752 and D6242 are not medically necessary. Our physician 
reviewer found there are multiple missing posterior teeth as noted by the numerous pontic (replacement) teeth 
requested for the fixed bridge. Given the Plan limits on bridges only being considered where there is one missing 
upper anterior tooth or two adjacent lower anterior teeth, there would be no finding of necessity as here are 
multiple missing teeth in the arch. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of retainer crowns (D6752) and pontic - porcelain fused to metal have not been 
met. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6752) for teeth #2, 
#4, #5, #6, #11, and #12, and pontic - porcelain fused to metal (D6242) for teeth #10, #13, #3, #7, #8, and #9 to 
be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a vestibuloplasty - ridge extension (secondary 
epithelialization) (D7340). 
 
You asked the Plan to pre-approve a vestibuloplasty. You say that you feel this was a medical procedure that 
should be covered. The Plan denied your request. The Plan says this service is not covered under your 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 pre-approve a 
vestibuloplasty - ridge extension (secondary epithelialization) (D7340).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve combination use of Padcev, Pembrolizumab, and 
Dexamethasone Sodium Phosphate. 
 
You asked the Plan to pre-approve Padcev, Pembrolizumab, and Dexamethasone Sodium Phosphate. You say 
that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of 
authorization for these drugs is correct, because this combination is not being requested for a medically 
accepted indication. 
 
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 Padcev, Pembrolizumab, and 
Dexamethasone Sodium Phosphate. Our reviewer says that the enrollee does not meet the criteria for the 
requested combination of Padcev, Pembrolizumab, and Dexamethasone Sodium Phosphate. Our physician 
reviewer found the requested combination is not Food & Drug Administration (FDA) approved for the 
enrollee's diagnosis. The requested use is not supported by one of the major drug compendia or by clinical 
research appearing in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Padcev, Pembrolizumab, and Dexamethasone Sodium Phosphate have not been 
met. Therefore, we decided that the Plan does not have to pre-approve combination use of Padcev, 
Pembrolizumab, and Dexamethasone Sodium Phosphate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection provided on November 22, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an injection. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network and authorization is required prior 
to an out-of-network visit. 
 
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 an injection provided on November 22, 2021 by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 implant supported porcelain/ceramic crowns 
(D6065). 
 
You asked the Plan to pre-approve the dental services. You say that you have no teeth. You say that you cannot 
eat. You also say that you would like approval of all implants in order to eat well and recover from your 
physical conditions. The Plan denied your request. The Plan says dental implants and all associated services are 
excluded from coverage. 
 
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 implant supported 
crowns are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve 12 implant supported porcelain/ceramic crowns (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four implant-supported crowns (D6065).
You asked the Plan to pre-approve implant-supported crowns. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by 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 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. Therefore, we decided that the Plan does not have to pre-approve four implant-supported crowns (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the incisional biopsy of oral tissue-soft (D7286). 
 
You asked the Plan to pre-approve the incisional biopsy of oral tissue. You say that you need this service to see 
what is going on in your gums. The Plan denied your request. The Plan says this service is not covered under 
your benefits. 
 
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. Therefore, we decided that the Plan does not have to pre-approve the 
incisional biopsy of oral tissue-soft (D7286).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Acupuncture provided on November 9, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for Acupuncture. You say that that you were misinformed about requiring prior 
authorization. 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 Acupuncture provided on November 9, 2021 by an 
out-of-network (OON) provider.
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's needs cannot be met at a 
lower level of care. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH 
services do not meet the requirements for approval. 
 
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 does not require services at the LTACH that are not available at the 
acute care hospital where he is currently receiving care. All medically necessary care is being provided in the 
current acute care facility. The health plan has approved ongoing care in the current acute care facility. The 
requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Freestyle Lite Test Strips. 
 
You asked the Plan to pre-approve the Freestyle brand test strips. You say that the enrollee desires to use the 
Freestyle brand test strips. The Plan denied your request. The Plan says there is no medical reason provided as 
to why the enrollee cannot use the preferred glucose monitor test strips 
 
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the durable medical equipment 
(DME) to only those preferred brands and manufacturers as long as the enrollee retains access to all medically 
necessary items (including non-preferred brands).  
 
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 Freestyle brand test strips. Our 
reviewer says that the documentation does not support that the non-preferred brand is medically necessary. Our 
physician reviewer found the record does not indicate a medical reason that the preferred brand cannot be used. 
 
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 Freestyle brand test strips have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Freestyle Lite Test Strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99203) provided on 
December 28, 2021. 
 
You asked the Plan to waive the copayment for the office visit. You say that the services should be covered as 
you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 $35 
copayment for Physician/Practitioner services, including doctor' office visits.  
 
 
  You have been asked to pay a $35 copayment for a specialist office visit. 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 office visit (99203) provided on December 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided 
from June 3, 2021, through September 15, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, 
plans are not required to make payments for any services received by enrollees that are not provided directly by 
the Plan or through arrangements made by the Plan. 
 
The services at issue in this appeal were not provided in an emergency or urgent care situation. These services 
were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not 
have to pay for the chiropractic manipulative treatment (98941) provided from June 3, 2021, through 
September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of an Optimizer Smart device (0408T), a 
type of cardiac contractility modulation (CCM) system. 
 
You asked the Plan to pre-approve an Optimizer Smart device. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested service is 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 an Optimizer Smart device. Our 
reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that CCM systems remain the subject of multiple studies examining long-term 
efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy.  Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Optimizer Smart device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve implantation of an Optimizer Smart device (0408T), a type of cardiac 
contractility modulation (CCM) system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says medical necessity rules for the requested item have not been 
met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found 
that you may benefit from BiPAP support during sleep, which can provide the average volume assured pressure 
support (AVAPS) mode of support. There is no evidence of failure of BiPAP in the home setting when 
medically stable. Medicare does not cover a ventilator when used as BiPAP. 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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Doxorubicin HCL Liposome, Zirabev, Palonosetron, 
and Dexamethasone. 
 
You asked the Plan to pre-approve Doxorubicin HCL Liposome, Zirabev, Palonosetron, and Dexamethasone. 
You say that the services are necessary. The Plan denied your request. The Plan says based on the 
documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Doxorubicin HCL Liposome, Zirabev, 
Palonosetron, and Dexamethasone. Our reviewer says that the services are not medically necessary. Our 
physician reviewer found the review indicates that the documentation does not support that the Doxorubicin 
HCL Liposome, Zirabev, Palonosetron, and Dexamethasone are medically reasonable and necessary or safe 
and effective 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 Doxorubicin HCL Liposome, Zirabev, Palonosetron, and Dexamethasone have 
not been met. Therefore, we decided that the Plan does not have to pre-approve Doxorubicin HCL Liposome, 
Zirabev, Palonosetron, and Dexamethasone.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Romtech Portable Connect device. 
 
You asked the Plan to pre-approve a Rometch Portable Connect device. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a Romtech Portable Connect device.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 4, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the treatment received by the 
member was medically necessary. The Plan denied your request. The Plan says there is no referral letter from 
an in-network physician, and the services were not medically necessary. The Plan also says that these request 
for services are by a non-contracted 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 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 subsequent nursing facility care provided on 
January 4, 2022, by an out-of-network (OON) provider.