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

 
We decided that the Plan does not have to pre-approve Eylea. 
 
You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says the enrollee has not 
tried the preferred drug. 
 
 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 Eylea. Our physician reviewer found 
the enrollee has exudative age-related macular degeneration of the left eye. The Plan requires a trial of Avastin 
before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug. 
There is no documentation provided indicating that the Plans required drug would likely be less effective 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 Eylea have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Eylea.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric visit provided on May 6, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for psychiatric visit. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 psychiatric visit provided on May 6, 2022, by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Glucerna shakes. 
 
You asked the Plan to pre-approve Glucerna. You say that the enrollee has unintentional weight loss. The Plan 
denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. 
 
The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be 
appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan 
does not have to pre-approve Glucerna shakes.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cardiac catheter ablation. 
 
You asked the Plan to pre-approve the requested services. You say that the enrollee is reporting weakness and 
unsteady gait. The Plan denied your request. The Plan says the enrollee is asymptomatic. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician 
reviewer found that the enrollee has supraventricular tachycardia (SVT). The recorded arrhythmia was 
asymptomatic, and the enrollee was started on medication. The response to medication has not been assessed 
prior to the request to carry out this invasive procedure. At the current time, based on current guidelines as well 
as the records provided, the requested consider catheter ablation is not medically necessary in this 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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a cardiac catheter ablation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for five extractions (D7140), and an 
immediate maxillary denture (D5130) provided by a participating provider on December 8, 2021, to December 
21, 2021. 
 
You asked the Plan to waive the coinsurance for extractions and an immediate maxillary denture. You say that 
these dentures are ill-fitting. 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 50% 
coinsurance for extractions/in-network and a 70% coinsurance for complete dentures/in-network provider.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for extractions and a 70% coinsurance 
of the allowed amount for an immediate maxillary denture.  
Date of Service Allowed Amount Coinsurance Amount You Owe 
December 8, 2021 $1,021 70% $714.70 
December 21, 2021 $95 50% $47.50 
December 21, 2021 $95 50% $47.50 
December 21, 2021 $95 50% $47.50 
December 21, 2021 $95 50% $47.50 
December 21, 2021 $95 50% $47.50 
 
Total Amount Being Asked to Pay: $714.70 + $47.50 + $47.50 + $47.50 + $47.50 + $47.50 = $952.20 
 
This item/service falls within the extractions/in-network and complete dentures/in-network provider 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 coinsurance for five extractions (D7140), and an immediate 
maxillary denture (D5130) provided by a participating provider on December 8, 2021, to December 21, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for full-time nursing services in the home provided from June 
12, 2022, to July 31, 2022. 
 
You asked the Plan to pay for home nursing. You say that you do not understand why this is not being 
reimbursed. The Plan denied your request. The Plan says full-time nursing care in the home is not covered by 
Medicare. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home nursing have not been met. Specifically, we find that the services at issue in this case are 
considered custodial in nature. Therefore, we decided that the Plan does not have to pay for full-time nursing 
services in the home provided from June 12, 2022, to July 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of  removal of residual tooth roots (D7250) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not meet the clinical requirements to be approved. 
 
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 
removal of removal of residual tooth roots (D7250)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2750) provided on July 26, 2022. 
 
You asked the Plan to pay more for the crown. You say that you would like the denial of payment to be 
reversed. The Plan denied your request. The Plan says the cost share for this service applied correctly. 
 
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, you are responsible for a 50% 
coinsurance for the crown. Therefore, we decided that the Plan does not have to pay more for the crown 
(D2750) provided on July 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Full mouth debridement and tooth extraction (D4355, 
D7210) provided on April 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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 pay for a Full 
mouth debridement and tooth extraction (D4355, D7210) provided on April 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 5, 2022.

You asked the Plan to pay for the comprehensive oral evaluation. You say that this exam was necessary because you switched dental providers. 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 Plan's 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 April 15, 2021. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150)provided on August 5, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tier exception for Tacrolimus. 
 
You asked the Plan to pre-approve a tier exception. You say that the medication costs too much. The Plan 
denied your request. The Plan says a tier exception is not available for Part B drugs. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance).  
 
We looked at the file and the rules. Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs. The requested drug falls within the Medicare Part B 
prescription drugs 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 pre-approve a tier exception for Tacrolimus.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on June 
07, 2022. 
 
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you should not have to 
pay this large copayment. 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 $2000 
maximum-out-of-pocket (MOOP) for covered services and a $400 deductible for Annual out-of-pocket 
amounts.  
 
You have been asked to pay a $437.87 for a diagnostic colonoscopy. This item/service falls within the Annual 
out-of-pocket amounts benefits category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a diagnostic 
colonoscopy provided on June 07, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the LTACH is the most appropriate level 
of care for the enrollee. The Plan denied your request. The Plan says the enrollee does not have clinical 
conditions that cannot be treated in the current hospital. 
 
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 appears to be improving and stable and should require only short-
term additional acute care services that can safely be provided at the current facility until more appropriate for a 
lower level of care. The enrollee does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. Transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous. Completion of treatment at the current facility is recommended. 
 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 the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline complete mandibular denture (D5751) provided on 
July 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was not clear that only one reline would be 
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 the same date of service, July 27, 2022. 
Therefore, we decided that the Plan does not have to pay for the reline complete mandibular denture (D5751) 
provided on July 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composites (D2330) provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve resin-based composites. You say that these services are needed due to oral 
health concerns. The Plan denied your request. The Plan says the requested dental service is not a covered 
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 pre-approve 
resin-based composites (D2330) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retreatment of a previous root canal (D3347) for tooth #5 
provided by an out-of-network provider on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the first root canal only took one of the two 
roots out. 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 May 7, 2021. Therefore, 
we decided that the Plan does not have to pay for the retreatment of a previous root canal (D3347) for tooth #5 
provided by an out-of-network provider on August 8, 2022.
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 
bitewing x-ray (D0270) provided on July 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to appeal these services. 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 Plan's 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 3, 2022. 
Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation 
(D0140) and bitewing x-ray (D0270) provided on July 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a tooth extraction (D7210) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. 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 Plan's 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 February 11, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a tooth extraction (D7210)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller, harness for upgrade to 
expandable controller, and the electronic connection between wheelchair controller and 2 or more power 
seating system motors. 
 
You asked the Plan to pre-approve an expandable controller, harness for upgrade to expandable controller, and 
the electronic connection between wheelchair controller and 2 or more power seating system motors. You say 
that you disagree with the Plan's denial. The Plan denied your request. The Plan says the requested items are 
not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that power wheelchair accessories are only covered 
for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that your upper limb strength and function 
are adequate for you to be able to control the power options using their own switches which are included in the 
allowance of these power options. The approved power options come with their own switches. Based on this 
information, we decided that Medicare rules for coverage of an expandable controller, harness for upgrade to 
expandable controller, and the electronic connection between wheelchair controller and 2 or more power 
seating system motors have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
expandable controller, harness for upgrade to expandable controller, and the electronic connection between 
wheelchair controller and 2 or more power seating system motors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image tooth #'s 01 and 32 
(D0330) provided on July 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had a sore jaw and saw a dentist who 
suggested taking new x-rays. 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 April 13, 2021. 
Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image tooth #'s 01 and 
32 (D0330) provided on July 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral exam and intraoral x-ray (D0150, 
D0210) provided on March 2, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 Plan's 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 April 19, 2019. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral exam and intraoral x-ray 
(D0150, D0210) provided on March 2, 2022.