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

 
We decided that the Plan does not have to pay for the second pair of eyeglasses provided on January 4, 2022. 
 You asked the Plan to pay for the eyeglasses. You say that this service should be paid. The Plan denied your 
request. The Plan says they have agreed to cover one pair of eyeglasses; however, your benefit covers a 
maximum of one pair per year. The second pair exceeds what is covered by your benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services for up to one pair per year. 
 
We looked at the file and the Plan's rules. The Plan has indicated that they have agreed to pay for a separate 
pair of routine eyeglasses which you purchased in 2022. Based on this information, we decided that the Plan's 
rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to 
pay for the second pair of eyeglasses provided on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the routine vision services provided on December 22, 
2021. 
 You asked the Plan to pre-approve the routine vision services. You say that the service should be covered. The 
Plan denied your request. The Plan says this service was obtained out-of-network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when obtained through the Plans network providers. 
 
The services you asked the Plan to pre-approve are considered routine vision services or eyewear and were not 
obtained through a network provider. Therefore, we decided that the Plan does not have to pre-approve the 
routine vision services provided on December 22, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Abraxane (CPT code J9264) and Bevacizumab-BVZR 
(CPT code Q5118). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drugs: 
Taxol (conventional paclitaxel) OR Taxotere (docetaxel).  
 
 The Plan states there is no indication the Plan's preferred drug(s) would likely be: less effective, cause adverse 
effects, and/or hypersensitivity reactions for the member. The Plan states there is no evidence the member has 
contraindications to the hypersensitivity pre-medications used with the step therapy drugs. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the medication. Our physician reviewer 
found the case file does not contain documentation of trial and failure of Taxol (conventional paclitaxel) OR 
Taxotere (docetaxel). The documentation does not support that Taxol (conventional paclitaxel) OR Taxotere 
(docetaxel) would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Abraxane (CPT code J9264) and Bevacizumab-BVZR (CPT code Q5118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drug, single administration (CPT 
code D9610), bone replacement graft  retained natural tooth  first site in quadrant (D4263 x 4) and osseous 
surgery (including elevation of a full thickness flap and closure)  four or more contiguous teeth or tooth 
bounded spaces per quadrant (D4260 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied 
your request. The Plan says the services are not a covered benefit under the 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. The services are not listed in your EOC as a covered benefit; therefore, 
the services are not covered. Therefore, we decided that the Plan does not have to pre-approve therapeutic 
parenteral drug, single administration (CPT code D9610), bone replacement graft  retained natural tooth  first 
site in quadrant (D4263 x 4) and osseous surgery (including elevation of a full thickness flap and closure)  
four or more contiguous teeth or tooth bounded spaces per quadrant (D4260 x 4).
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the record indicates that you are improving but still require acute care services before 
transitioning to a lower level of care. You continue to receive acute care services, and these have not been 
denied. The medical record does not indicate that you require services that you are not currently receiving but 
that would be available at the LTACH facility. 
 
 
 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: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve correction, hallux valgus (bunionectomy), with sesamoidectomy, 
when performed; with distal metatarsal osteotomy, any method (CPT code 28296). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says that the enrollee's records do not show that any nonoperative therapies have 
been tried and/or failed. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 the service. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found Medicare guidelines advise that Medicare will pay for treatment to improve the functioning of a 
malformed body member. This procedure must be safe and effective, not mainly for the convenience of the 
enrollee or the physician, not experimental or investigational, furnished in accordance with accepted standards 
of medical practice to improve the functioning of a malformed body member, and a treatment that meets but 
does not exceed the enrollees medical needs. In this particular case, the requested bunionectomy meets the 
Medicare authorization guidelines above. Therefore, the requested correction, hallux valgus bunionectomy, 
with sesamoidectomy, when performed; with distal metatarsal osteotomy, any method, CPT code 28296 is 
medically reasonable and 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 the service have been met. Therefore, we decided that the Plan has to pre-
approve correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal 
metatarsal osteotomy, any method (CPT code 28296).  
 
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 waive the deductible for the eye exam (92004) provided on October 
25, 2021. 
 
You asked the Plan to waive the deductible for the eye exam. You say that you expected to only be responsible 
for your $40 copayment for a specialist visit. The Plan denied your request. The Plan says this claim was 
processed in accordance with your contract. You had not met your deductible before the date in question. The 
Plan does not pay for certain services, such as medical eye exams, until this deductible is met. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $150 deductible which applies to Medicare-covered vision care 
exams.  
 
The item or service you asked the Plan to waive the deductible for is a Medicare-covered vision care exam. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $150 deductible which 
applies to Medicare-covered vision care exams. This cost sharing is a contractual obligation that had not been 
met at the time the eye exam was received on October 25, 2021. Therefore, we decided that the Plan does not 
have to waive the deductible for the eye exam (92004) provided on October 25, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on February 14, 2022. 
 
You asked the Plan to pay for the services provided. You say that coding is not limited to the final diagnosis. 
The Plan denied your request. The Plan says the enrollee did not require medical decision of high complexity. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99284 is emergency department visit for the evaluation 
and management of a patient. Usually, the presenting problem(s) are of high severity, and require urgent 
evaluation by the physician, or other qualified health care professionals but do not pose an immediate 
significant threat to life or physiologic function. We find that CPT code 99284 is not supported in the medical record. The records show that the enrollee 
presented to the emergency room with urinary retention, for which a catheter was replaced. The records do not 
show that the presenting problem was of high severity. Based on this information, we decided that Medicare 
rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not 
have to pay for the emergency room services provided on February 14, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee's medical management and rehabilitation 
needs require an inpatient stay and close physical supervision in order to regain their maximum function. The 
Plan denied your request. The Plan says the records show that the enrollee does not require supervision of a 
rehabilitation doctor. The enrollee can safely receive the services needed in other settings, for example, a 
skilled nursing facility, home with home physical therapy, or home with outpatient therapy. 
 
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 enrollee had a fall and was found to have a lung 
infection and confusion. Breathing problems improved, confusion is noted to have resolved, and additional 
medical concerns were stabilized. There are no complex nursing or rehabilitation needs. While you have a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PBT (CPT code(s): 77263, 77293, 77295, 77300, 
77301, 77334, 77336, 77427, 77470, 77520, 77522, 77523, 77525, 77387, and G6002). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of Proton Beam Therapy in the setting 
of rectal adenocarcinoma have not been demonstrated in the peer-reviewed literature. 
 
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 services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found PBT in the setting of rectal adenocarcinoma is not medically reasonable and necessary. The 
clinical value and effectiveness of PBT in the setting of rectal adenocarcinoma have not been demonstrated in 
the peer-reviewed literature. Per NCCN Guidelines for Rectal Cancer: Radiotherapy should be delivered in a 
highly conformal manner. The techniques can include 3D conformal radiation therapy, intensity-modulated 
therapy (IMRT), or stereotactic body radiation therapy (SBRT). The scientific literature has not shown benefit 
for the use of PBT over IMRT. 
 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the PBT (CPT code(s): 77263, 77293, 77295, 77300, 77301, 77334, 77336, 77427, 77470, 
77520, 77522, 77523, 77525, 77387, and G6002).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy visits (CPT code G0151 x 
3). 
 
You asked the Plan to pre-approve the home health physical therapy visits. You say that the services are 
necessary. The Plan denied your request. The Plan says the enrollee's records do not support the need for a 
skilled physical therapist to make more home visits at this time. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 home health physical therapy visits. 
Our physician reviewer found the documentation does not support that the enrollee requires additional skilled 
rehabilitation services to provide treatment that is medically necessary. The enrollee does not require additional 
skilled nursing services to effectively provide treatment, care, and/or services in order to improve the enrollees 
condition, perform a maintenance program to maintain the enrollees condition and/or prevent deterioration. 
The enrollee has been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. The requested home health services are not 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 the home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home health physical therapy visits (CPT code G0151 x 3).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve unlisted procedure, nervous system (CPT code 64999). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the appropriate CPT code 61580 for craniofacial approach has already been approved as 
was advised to the doctor. The Plan states the requested code 64999 is the incorrect code and appears to be a 
duplicate service already approved with the correct CPT code for a transsphenoidal approach. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. The requested code 64999 is the incorrect code 
and appears to be a duplicate service already approved with the correct CPT code for a transsphenoidal 
approach. Therefore, we decided that the Plan does not have to pre-approve unlisted procedure, nervous system 
(CPT code 64999).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve periodontal scaling and root planning (code D4342). 
 
You asked the Plan to pre-approve periodontal scaling and root planning. You say that you would like this 
service covered. The Plan denied your request. The Plan says that the enrollee has exhausted his dental benefit 
on February 14, 2022. 
 
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 did not provide evidence that the dental benefit for periodontal scaling 
and root planning has been exhausted. Therefore, we decided that the Plan has to pre-approve periodontal 
scaling and root planning (code D4342).  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT 
code 22870). 
 
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the Medicare criteria for reasonable and necessary are not met as it has not 
been shown to be safe and effective in long term studies and there is a lack of evidence to support that 
interspinous spacer devices are as safe and effective as the gold standard of decompression. The Plan states this 
procedure is indicated for treatment of patients with moderate spinal stenosis and relief in bending and is not 
intended for patients with severe spinal stenosis or scoliosis. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the 
medical necessity of this request as an exception. Therefore, the request for Vertiflex Superion interspinous 
device at L3-4 and L4-5 is not medically reasonable or 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22870).
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 requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 the record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. The enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that he is 
not currently receiving but that would be available at the LTACH facility. 
 
  
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.