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

 
We decided that the Plan does not have to pay more for a porcelain/ceramic crown (D2740) on tooth #10 
provided on March 25, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the service covered. 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 your benefit for the requested item or service was exhausted on date of service March 25, 2022.  Please note that the crowns on teeth #7, #8, and #9 were fully paid. Partial payment was made on tooth #10, 
however your $3,000 out-of-pocket maximum was met. You are responsible for the remaining costs. Therefore, 
we decided that the Plan does not have to pay more for a porcelain/ceramic crown (D2740) on tooth #10 
provided on March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  a pontic (D6240) for tooth number 3,  a retainer crown 
(D6750) for teeth number 2 and 4. 
 
You asked the Plan to pre-approve  a pontic (D6240) for tooth number 3,  a retainer crown (D6750) for teeth 
number 2 and 4. You say that you are uncomfortable eating. You also say you are unable to eat food properly. 
The Plan denied your request. The Plan says this service is not covered under your benefit plan. 
 
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 
pontic (D6240) for tooth number 3,  a retainer crown (D6750) for teeth number 2 and 4.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional hours per week of home health aide 
(HHA) services. 
 
You asked the Plan to pre-approve 10 additional hours per week of HHA services. You say that you are very 
delicate, and all of your doctors agree you need the full four hours for the maintenance of your health. The Plan 
denied your request. The Plan says this request is not considered medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 10 additional hours per week of HHA 
services. Our reviewer says that HHA services are not shown to be medically necessary or reasonable. Our 
physician reviewer found you do not have documented skilled nursing needs. Our reviewer also found that you 
do not have documented skilled therapy needs. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional hours per week of HHA services have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 10 additional hours per week of home health aide (HHA) 
services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve routine dental care. 
 
You asked the Plan to pre-approve routine dental care. You say that the services are medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested dental services are not covered under 
Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
routine dental care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar laminectomy. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the documentation does not support 
that the enrollee has tried and failed conservative measures for back pain. More conservative measures, such as 
physical therapy, are needed prior to surgery. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve lumbar laminectomy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 12, 2022, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from November 12, 2022, forward. You say that 
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not medically necessary. 
 The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
November 12, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient 
mental health treatment beyond the date in question of November 12, 2022, forward. Our physician reviewer 
found the enrollee did not require inpatient mental health treatment beyond November 12, 2022, as he was not 
a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear 
that active treatment was taking place beyond the date in question. It did not appear that the services for the 
dates in question were reasonably expected or medically necessary to improve the enrollees condition or for 
the purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from November 12, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 12, 
2022, forward.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has metastatic serous 
endometrial carcinoma. The record indicates that the enrollee has failed previous chemotherapy options and the 
requested drug is being administered as monotherapy. The Food and Drug Administration (FDA) has not stated 
that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia 
do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. 
Keytruda is therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to an IRF 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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer 
found that the documentation shows that the enrollee has complex functional impairments including spasticity 
and clonus. The evaluating therapists state that the enrollee would tolerate intense therapy and the enrollee is 
making progress with therapy evaluations. Clinical documentation shows that the enrollee has active 
comorbidities (spasticity, contractures) due to neuromyelitis optica and would be expected to require continued 
inpatient hospitalization for close medical monitoring during rehabilitation (primary team also documents that 
the enrollee will benefit from medical monitoring status post steroid wean). 
 
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 been met. Therefore, we decided that the Plan has to pre-approve 
acute inpatient rehabilitation facility (IRF) admission and services.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 documentation shows that the enrollee has functional impairments but there are 
no complex functional deficits listed (only generalized weakness and pain). It is noted that the enrollee was 
evaluated for cauda equina but was discovered to have lumbar stenosis on previous admission thus there is no 
documentation to show that the enrollee would require intense therapy or interdisciplinary team management of 
rehabilitation in an IRF setting. Clinical documentation does not list any active comorbidities. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen concentrator you purchased on March 
17, 2022. 
 
You asked the Plan to pay for the portable oxygen concentrator. The Plan denied your request. The Plan says 
this is not a covered benefit. 
 
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 an 18% 
coinsurance for in-network oxygen equipment rentals.  
 
Review of the file shows that you purchased a portable oxygen concentrator on Marcy 17, 2022. The Plan only 
covered oxygen equipment rentals. As such, the requested portable oxygen concentrator is not covered. This 
means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we 
decided that the Plan does not have to pay for the portable oxygen concentrator you purchased on March 17, 
2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Prostate Artery Embolization (PAE). 
 
You asked the Plan to pre-approve a PAE. You say that the service is medically necessary. The Plan denied 
your request. The Plan says this service is experimental. 
 
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 a PAE. Our reviewer says that the 
requested service is not considered medically reasonable and necessary in this case. Our physician reviewer 
found this service is considered experimental, and more research is needed to show its safety and efficacy. 
 
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 PAE have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a Prostate Artery Embolization (PAE).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer first. 
 
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 Injectafer. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found the Plan requires a trial of Infed 
and Venofer first 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 Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Oxycodone tablet. 
 
You asked the Plan to pre-approve Oxycodone. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical 
benefit. 
 
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 Oxycodone tablet.  
 
Benefits for Oxycodone 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: 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 will require intensive therapies with an 
interdisciplinary approach to regain strength and prevent further disability. The Plan denied your request. The 
Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval. 
 
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 that the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollees care needs can be met at a lower level of care. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (64483). 
 
You asked the Plan to pre-approve a repeat epidural steroid injection. You say that you are not happy with the 
Plan because you have to jump through hoops to get your services approved. The Plan denied your request. The 
Plan says there is no documentation of greater than 50% reduction in pain at 3 months, and for this reason this 
cannot be approved unless this is provided. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or 
improvement in function measured from baseline using the same scale. 
 
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 repeat epidural steroid injection. Our 
reviewer says that the review has determined that the repeat epidural steroid injection is not medically 
reasonable or necessary. Our physician reviewer found the medical record did not document at least 50% of 
sustained improvement in pain relief and/or improvement in function measured from baseline using the same 
scale for at least three months. 
 
 
 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 repeat epidural steroid injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a repeat epidural steroid injection (64483).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body: endosteal 
implant tooth #'s 22, 27 (D6010), and add metal substructure to acrylic full denture (per arch) (D5876). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says these 
services are not covered under the benefit package. 
 
 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 surgical placement of implant 
body: endosteal implant tooth #'s 22, 27 (D6010), and, add metal substructure to acrylic full denture (per arch) 
(D5876) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pre-approve the surgical placement of implant body: endosteal implant tooth #'s 22, 27 (D6010), and add metal 
substructure to acrylic full denture (per arch) (D5876). The Plan agreed to pre-approve the implant /abutment 
supported removable denture for edentulous arch  mandibular (D6111).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the collection and application of autologous blood 
concentrate product (D7921) for tooth number 2. 
 
  You asked the Plan to pre-approve the collection and application of autologous blood concentrate product 
(D7921). You say that tooth number 2 is not restorable, deep decay under gum line, not visible canals, and 
extraction is already approved by the Plan's consultants. You also say you do not understand why the patient 
cannot have his implant to restore if it is part of his benefits. The Plan denied your request. The Plan says the 
collection and application of autologous blood concentrate product (D7921) for tooth number 2 is 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
collection and application of autologous blood concentrate product (D7921) for tooth number 2.