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

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #12 and a core buildup, 
including any pins when required (D2950) for tooth #12. 
 
You asked the Plan to pre-approve a crown and core buildup. The Plan denied your request. The Plan says the 
documentation submitted does not demonstrate the need for replacement of the existing crown. The Plan also 
says that core buildup is not covered under the enrollee's 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. The Plan covers a crown and 
core buildup when the services are medically necessary and reasonable.   
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a crown for tooth #12. Our reviewer 
says that a replacement crown is not necessary. Our physician reviewer found the supplied documentation 
shows a crown on tooth #12 that has a fracture in the porcelain with clear discoloration in the fractured 
segment. The x-rays do not show any missing porcelain, so the contacts between the teeth appear to be intact. 
Our reviewer found that the function of the crown appears to be unaffected by the noted fracture, and the only 
effect of the fracture at this point appears to be cosmetic only and until such time a fracture compromises the 
functioning of the crown by allowing food impaction or occlusal dysfunction. Our physician reviewer also 
found that at the present time, the crown on tooth #12 is functional and not in need of replacement. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown and core buildup have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a crown (D2740) for tooth #12 and a core buildup, including any pins when 
required (D2950) for tooth #12.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (CPT code J0897). 
 
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 there is no indication the enrollee has had an osteoporosis-related 
fracture. The Plan states the enrollee has not tried and failed zoledronic acid. The Plan states there is no 
indication zoledronic acid, an intravenous (IV) bisphosphonate drug, would likely be: less effective, and/or 
cause adverse effects for the enrollee.  
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 enrollee does not have a history of osteoporosis-related fracture and the enrollee has not tried and 
failed the required drug(s). The documentation does not support that Zoledronic acid 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 Prolia (CPT code J0897).  
 
Benefits for the medication 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture services provided to the enrollee from 
December 8, 2021, to December 22, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says out-of-network providers are not covered. 
 
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 acupuncture services provided to the enrollee from 
December 8, 2021, to December 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Victoza injections. 
 
You asked the Plan to pre-approve Victoza injections. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Victoza injections are not covered under the enrollee's 
Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Victoza injections.  
 Benefits for Victoza injections 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a replacement advanced foot feature for your prosthetic 
leg. 
 
You asked the Plan to pre-approve a replacement advanced foot feature for your prosthetic leg. You say that 
the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, 
coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare pays for the least expensive option of 
repair vs. replacement of durable medical equipment (DME). Replacement due to wear is not covered during 
the reasonable useful lifetime of the equipment.  
 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a replacement advanced foot feature for your prosthetic leg have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a replacement advanced foot feature for your prosthetic leg.
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 services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 as LTACHs and acute care hospitals (ACHs) are licensed to provide the same level 
of care, there is no advantage in transferring you to the LTACH.  You can remain at the current ACH until such 
time no acute services are required. You can then be transferred/discharged to a lower level of care for any 
ongoing long-term care needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cataract surgery with a toric lens. 
 
You asked the Plan to pre-approve the cataract surgery with a toric lens. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is non-covered. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pre-approve cataract surgery 
with a toric lens.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapy services (97110, 97165) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says there are network providers available. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve therapy 
services (97110, 97165) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) discharge services provided to 
the enrollee on September 20, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) 99316 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation does not include a 
discharge service provided on September 20, 2021. The documentation includes a progress note for this date of 
service. This procedure code cannot be verified. 
 
We looked at this coder'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 pay for skilled nursing facility (SNF) discharge services provided to the enrollee on September 20, 
2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ultrasound (37253) provided October 18, 2021. 
 
You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 37253 is not supported in the medical record. Specifically, the records do not support 2 
units of service. Based on this information, we decided that Medicare rules for coverage of the ultrasound have 
not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (37253) provided 
October 18, 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 the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or currently to be able to tolerate, fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollees care needs can be met at a lower level of 
care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a general health panel received on September 24, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says this service is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that a GHP (code 80050) is not covered or paid for by 
Medicare. However, a GHP consists of three separate lab services which may be billed and paid for separately: 
 
1. a comprehensive metabolic panel (CMP; code 80053); 
 
2. a complete blood count (CBC; code 85025); 
 
3. a thyroid stimulating hormone (TSH; code 84443). 
 
The rules say that CMPs are covered when they are reasonable and necessary. The rules say that CBCs and TSHs are covered only for certain medical indications. 
 
You have requested payment for a GHP, billed under code 80050. Medicare does not cover or pay for services 
billed under this code. Therefore, the Plan does not have to pay for the GHP billed under code 80050. 
 
Because payment cannot be made for the GHP, we looked to see if rules had been met for the three services 
that comprise a GHP. 
 
With respect to the CMP, 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 testing Our 
reviewer says that  Our physician reviewer found   
 
We looked at this physician's review, the file and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CMP have not been met. Therefore, the Plan does not have to pay for the 
CMP. 
 
With respect to the CBC, we found that you do not have a medical condition for which this service may be 
covered. Therefore, the Plan does not have to pay for the CBC. 
 
With respect to the TSH, we found that you do not have a medical condition for which this service may be 
covered. Therefore, the Plan does not have to pay for the TSH. Therefore, we decided that the Plan does not 
have to pay for a general health panel received on September 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pure wick urine collection system (K1006). 
 
You asked the Plan to pre-approve the pure wick urine collection system. You say that this item is medically 
necessary. The Plan denied your request. The Plan says this item is a convenience item and is non-covered. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a pure wick urine collection system (K1006).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility services. 
 
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 the skilled nursing facility services. Our 
reviewer says that daily skilled services are not necessary. Our physician reviewer found the provided records 
do not document a significant decline in the patients functional status compared to her recent baseline to 
necessitate daily inpatient skilled therapy 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 the skilled nursing facility services have not been met. Therefore, we decided 
that the Plan does not have to pre-approve skilled nursing facility 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 IRF services are medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
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 there is not a reasonable expectation that this patient 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from November 5, 2021, to December 4, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says there was no daily skilled nurse or therapist need. 
 
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 pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee did not have documented skilled 
nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not 
required to establish a maintenance program or to prevent deterioration of the enrollees condition. The 
enrollees care needs, custodial and intermittent, could, as a practical matter, be provided at a lower level of 
care. The enrollee no longer qualified for SNF coverage after 11/4/2021. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from November 5, 2021, to 
December 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81206, 81235, 81292, 81301, 81321, 81162, 
81295, 81298, 81317, 81402, 81194, 81309) provided June 8, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services (81206, 81235, 81292, 81301, 81321, 81162, 81295, 81298, 
81317, 81402, 81194, 81309) provided June 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Brovana (J7605). 
 
You asked the Plan to pre-approve Brovana. The Plan denied your request. The Plan says this request does not 
meet the Plan's Part B step therapy criteria for Brovana. 
 
  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 Brovana. Our reviewer says that 
Brovana is not medically reasonable and necessary. Our physician reviewer found there is no indication that the 
patient has tried and failed the required drug, Perforomist (Formoterol). Our reviewer also found that there is 
no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for 
the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Brovana have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Brovana (J7605).