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 this is medically necessary. The Plan denied your 
request. The Plan says needs can be safely met at a lower level of care, such as skilled nursing facility or home 
with home health. 
 
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 review has determined that the complexity of the enrollee's nursing, medical and 
rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable 
expectation that this enrollee will 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided on September 
20, 2021. 
 
You asked the Plan to pay for the crown. You say that you were not aware this was not a covered service and 
would have purchased other insurance if you had known. The Plan denied your request. The Plan says this 
service is not covered by your dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 pay for the 
porcelain/ceramic crown (D2740) provided on September 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the hearing aid accessory provided on
October 14, 2021.
You asked the Plan to reimburse you for the hearing aid accessory. The Plan denied your request. The Plan says hearing aid accessories are not a covered benefit under any condition.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that hearing aid accessories are not covered under any condition. Therefore, we decided that the Plan does not have to reimburse you for the hearing aid accessory provided on October 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve four surgical placements of implant bodies: endosteal 
implants (D6010 x4) and two bone grafts at time of implant placement (D6104 x2). 
 
You asked the Plan to pre-approve the endosteal implants and bone grafts. You say that you really need these 
services to be approved because you cannot eat or sleep, and you have lost weight. The Plan denied your 
request. The Plan says these services are 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 four 
surgical placements of implant bodies: endosteal implants (D6010 x4) and two bone grafts at time of implant 
placement (D6104 x2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Carboplatin (J9045), Bevacizumab-Awwb (Q5107), and 
Docetaxel (J9171). 
 
You asked the Plan to pre-approve Carboplatin, Bevacizumab-Awwb, and Docetaxel. The Plan denied your 
request. The Plan says the National Comprehensive Cancer Network (NCCN) does not recognize the use of 
Carboplatin plus Docetaxel plus Bevacizumab as therapy for cervical cancer. The Plan also says that this is not 
valid therapy based on the NCCN or literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
 
  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Carboplatin, Bevacizumab-Awwb, and 
Docetaxel. Our reviewer says that Carboplatin, Bevacizumab-Awwb, and Docetaxel are not medically 
reasonable and necessary for the enrollee. Our physician reviewer found the requested use of Carboplatin 
(J9045), Bevacizumab-Awwb (Q5107), and Docetaxel (J9171) is not FDA-approved for the enrollees 
diagnosis as 3rd line therapy. Our reviewer found that the use of these drugs is not supported by one of the 
major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services 
approved medical journal. Our physician reviewer also found that the use of these drugs is not listed as not 
indicated, not supported or not recommended in any of the compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Carboplatin, Bevacizumab-Awwb, and Docetaxel have not been met. Therefore, 
we decided that the Plan does not have to pre-approve Carboplatin (J9045), Bevacizumab-Awwb (Q5107), and 
Docetaxel (J9171).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-
rays (D0274), initial periapical x-ray (D0220), additional periapical x-ray (D0230), and filling (D2393) 
provided from May 3, 2021, to May 6, 2021, by an out of network provider. 
 
You asked the Plan to pay for the dental services. You say that you confirmed that the provider in this case was 
in network. You also say that the service should be covered. The Plan denied your request. The Plan says 
dental services received out of network 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental services received out of network 
are not among those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for the oral exam (D0120), prophylaxis (D1110), bitewing x-rays (D0274), initial periapical x-ray (D0220), additional periapical x-ray (D0230), and filling (D2393) provided from May 3, 2021, to May 6, 2021, by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for treatment with self-administered drugs provided on August 6, 2021. 
 
You asked the Plan to pay for self-administered drugs. You say that the drugs at issue were a medical necessity 
for the enrollee. The Plan denied your request. The Plan says rules for payment 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 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 pay for treatment with self-administered 
drugs provided on August 6, 2021.  
 
Benefits for self-administered drugs 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 
22, 2021. 
 
You asked the Plan to pay for the dental service. You say that the service that you received was medically 
necessary and appropriate. You also say that the service should be covered. The Plan denied your request. The 
Plan says limited oral evaluation is not listed as a covered service. 
 
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 limited oral evaluation is not 
among those covered under this benefit, regardless of the provider's network status. Therefore, we decided that 
the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided September 14, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the tooth extraction. You say that you needed your tooth fixed before your 
vacation. The Plan denied your request. The Plan says this service is not covered when provided OON. 
 
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 tooth 
extraction when the services are rendered by a provider in the Plans dental vendor network.  
 
We looked at the file and Medicare rules. 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. Based on this information, we decided that the Plan's rules for coverage of 
the tooth extraction have not been met. Therefore, we decided that the Plan does not have to pay for the 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided September 14, 
2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint injections. 
 
You asked the Plan to pre-approve facet joint injections. You say that this is medically necessary. 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 the need for a three or four-level facet joint procedure 
bilaterally may be considered under unique circumstances and with sufficient documentation of medical 
necessity on appeal 
 
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 facet joint injections. Our reviewer says 
that the requested services are not medically reasonable and necessary. Our physician reviewer found that the 
review indicates that the enrollee is an 87-year-old female with a history of chronic low back pain due to 
lumbosacral spondylosis, status post L3-L5 fusion. On December 2, 2021, she stated that the pain radiated to 
the left buttock and on physical examination lumbar extension was painful. Her provider has recommended 
facet injections at L3-S1 (L3-L4, L4-L5, and L5-S1). The review has determined that the enrollee does not 
satisfy the coverage criteria for the requested facet joint injection services as there is no unique circumstance to 
allow a three or four level procedure. The facet joint injections are 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 facet joint injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of an impacted tooth, partially bony, (D7230) 
for tooth # 32. 
 
You asked the Plan to pre-approve the dental service. You say that this tooth is causing your pain. You say that 
you are not able to chew on that side of your mouth. The Plan denied your request. The Plan says removal of an 
impacted tooth, partially bony, is not listed as a covered service. 
 
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 removal of an impacted 
tooth, partially bony, is not among those covered under this benefit. Therefore, we decided that the Plan does 
not have to pre-approve removal of an impacted tooth, partially bony, (D7230) for tooth # 32.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abutment supported crown (D6058) provided on 
September 8, 2021. 
 
You asked the Plan to pay for the dental service. You say that you do not understand the difference between the 
service you received and a crown. You say that you do not want another crown that will fall out of your mouth. 
You also say that this was an emergency. The Plan denied your request. The Plan says implant and implant 
related services 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the abutment supported crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the abutment supported crown (D6058) provided on September 8, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2391) provided on December 
11, 2020, by a Medicare opt out provider. 
 
You asked the Plan to pay for the resin-based composite. You say that you used the same doctor in 2019 and 
you were reimbursed for the service. You also say that it is unfair that this claim was denied. The Plan denied 
your request. The Plan says this service was rendered by a privately contracted provider. 
 
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 
covered when they are rendered by a provider who has opted out of Medicare. Therefore, we decided that the 
Plan does not have to pay for the resin-based composite (D2391) provided on December 11, 2020, by a 
Medicare opt out provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your record does not show that you require daily skilled nursing or 
skilled therapy in a SNF setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet 
Medicare criteria for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
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 does not support that the complexity of your nursing, medical 
and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. The documentation does not support that you require at least 3 hours of therapy per day at 
least 5 days per week, or 15 hours over 7 consecutive days, of therapy services. It is not clear that you are 
reasonably expected to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Therapy services may be provided 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950) provided September 8, 2021. 
 
You asked the Plan to pay for the crown and core buildup. You say that these services have been partially 
covered in the past and a supervisor with the Plan indicated you would have partial coverage now. The Plan 
denied your request. The Plan says these services are not covered under your benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown 
- porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided September 
8, 2021.  
 
Your complaint about potentially receiving misinformation from a Plan representative is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an auricular nerve stimulator. 
 
You asked the Plan to pre-approve an auricular nerve stimulator. You say that this is medically necessary. The 
Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that an auricular nerve stimulator is non-covered.  
 
We looked at the file and Medicare rules. This item is not covered according to Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of an auricular nerve stimulator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an auricular nerve stimulator.