Persius/hicric huggingface dataset:
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 IRF care is medically necessary for you to regain 
your strength so you can return home. The Plan denied your request. The Plan says IRF care is not medically 
necessary and your needs can be met at an alternate level of care such as in a skilled nursing facility. 
 
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 there is not a reasonable expectation that you would 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services provided from January 23, 
2020, to January 24, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient acute level of care 
was appropriate after the attending physician considered all factors inclusive of medical history, severity of 
illness, medical necessity, medical predictability of adverse events, and intensity of service requirement. The 
Plan denied your request. The Plan says the request for an inpatient level of care is not supported.  
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 pay for the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the record did not show that at the time of inpatient admission the 
admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency 
department and/or observation care) would span two midnights. 
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the inpatient hospital services provided from January 23, 2020, to January 24, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the dental services. You say that you received approval for 3 crowns, 
however the core buildup and pins denied. You cannot place a crown without them. The Plan denied your 
request. The Plan says this item is not covered under the Plan 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 core 
buildup, including any pins when required (D2950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a power operated vehicle. You say that this is medically necessary for your 
condition. 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 a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a manual wheelchair. This means that Medicare rules 
for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
power operated vehicle (K0800).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa for the enrollee. 
 
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of Euflexxa in the setting of ankle arthritis have 
not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 Euflexxa. Our reviewer says that 
Euflexxa is not medically reasonable and necessary. The clinical value and effectiveness of Euflexxa in the 
setting of ankle arthritis has not been demonstrated in the peer-reviewed literature. The requested use of 
Euflexxa is not FDA-approved for the enrollees diagnosis. Its use is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal. Our physician reviewer 
found that the enrollee's condition does not meet criteria for coverage of Euflexxa. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve surgical services. You say that this doctor has been in charge of your 
medical care and knows your needs, so starting over with a new provider would jeopardize your healing and 
recovery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because this provider is out-of-network with the Plan and you can be treated by an in-network physician. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
surgical services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-ray (D0274) and periapical x-ray (D0230 x 2) 
provided on January 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. You also say 
that your 2 front teeth have been altered by inferior dental mistakes. You also say that you would like the 
damage to be repaired. The Plan denied your request. The Plan says the claim processed correctly. 
 
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 and the x-rays are listed as covered, the 
frequency limits have been exceeded. The record shows that the Plan paid for bitewing x-rays you received on 
October 19, 2021. The record also shows that the Plan paid for 1 periapical x-ray you received on July 16, 2021, 
July 26, 2021, October 14, 2021, and January 11, 2022. Therefore, we decided that the Plan does not 
have to pay for the bitewing x-ray (D0274) and periapical x-ray (D0230 x 2) provided on January 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on October 7, 
2021, by an out-of-network (OON) provider. 
 You asked the Plan to pay for the psychotherapy services. You say that you would like these claims 
reprocessed as you were unaware of network eligibility. The Plan denied your request. The Plan says prior 
authorization was not obtained for these services rendered by an OON 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 the psychotherapy services (90837) provided on 
October 7, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series x-ray (D0210) provided on February 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that 1 
complete series x-ray is covered every 3 plan years. The Plan also says that the frequency limits have been 
exceeded. 
 
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 and the services are listed as covered, 
they are limited to once every 3 plan years. The record shows that the Plan paid for a comprehensive oral evaluation and complete series x-ray that you received on December 21, 2020. Therefore, we decided that the 
Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete series x-ray (D0210) 
provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tooth extractions from an oral surgeon. 
 
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 services from an oral surgeon are not 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. The Plan covers supplemental 
dental benefits from a participating general dentist only. 
  
We looked at the file and the Plans rules. The file shows that you are requesting services from an oral surgeon. 
Based on this information, we decided that the Plan's rules for coverage of these services have not been met. 
Therefore, we decided that the Plan does not have to pre-approve tooth extractions from an oral surgeon.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary for your condition. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Xarelto tablet. 
 
You asked the Plan to pre-approve Xarelto. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Xarelto 
tablet.  
 Benefits for Xarelto 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
August 18, 2021. 
 
You asked the Plan to pay for the nursing facility care. You say that the medically necessary services were 
rendered to the enrollee in good faith. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
August 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara system. 
 
You asked the Plan to pre-approve the Volara system. You say that this equipment is medically necessary for 
the enrollee's condition. The Plan denied your request. The Plan says the Volara system is considered 
experimental at this time. 
 
The Plan must follow Medicare rules. Medicare rules say that IPV in the home setting is not covered. 
 
We looked at the file and Medicare rules. In this case, the Volara system includes an IPV device. Based on this 
information, we decided that Medicare rules for coverage of the Volara system have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the Volara system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and additional periapical 
x-rays (D0230 x 2) provided on January 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have not had a complete radiograph this 
current year. You also say that the services are necessary for a root canal and therefore should be covered. The 
Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says 
1 additional periapical x-ray is covered per year. The Plan also says that the frequency limit has been exceeded. 
 
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 limited oral evaluation is not among 
those covered under this benefit. Additionally, 1 additional periapical x-ray is covered per year. The 
record shows that the Plan paid for an additional periapical x-ray that you received on the date of service in this 
case. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), and 
additional periapical x-rays (D0230 x 2) provided on January 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is progressively getting 
better and stronger but needs to be placed in an LTACH so he can receive the treatment to head back to his 
home. The Plan denied your request. The Plan says based on Medicare guidelines, the requested 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: Imaging
Decision: Favorable

 
We decided that the Plan has to waive the copayment for the MRI provided on January 13, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that you are on a fixed income and cannot 
afford bills like this. The Plan denied your request. The Plan says that the copayment was applied 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 does not say in clear and accurate terms 
how much you should expect to pay for the MRI.  
 
We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $100 
copayment for an MRI. The Plan contract does not clearly say how much enrollees must pay for MRIs. This 
means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we 
decided that the Plan has to waive the copayment for the MRI provided on January 13, 2022.  
 
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 provide additional payment for the crowns - porcelain/ceramic 
(D2740) provided October 18, 2021. 
 
You asked the Plan to provide additional payment for the crowns. You say that you feel this claim has been 
denied in error. The Plan denied your request. The Plan says you have exhausted 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. The Plan covers the crowns up 
to a $1,000 annual maximum for covered supplemental dental services.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time the claim 
was processed you had $713 remaining in your annual dental maximum. This amount was applied to your 
crowns. You have been asked to pay the amount above your annual maximum. Therefore, we decided that the 
Plan does not have to provide additional payment for the crowns - porcelain/ceramic (D2740) provided October 
18, 2021.