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

 
We decided that the Plan does not have to pre-approve a crown (D2752) for tooth #15. 
 
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says for this service to 
approved more than half of your tooth must be damaged due to decay or injury. The Plan also says that based 
on the records (pictures/x-rays/notes) that your dentist sent in there are no signs that more than half of your 
tooth has damage that is from decay or injury. 
 
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. The Plan covers the crown 
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 the crown. Our reviewer says that a 
crown (D2752) for tooth #15 is not medically reasonable or necessary. Our physician reviewer found the 
provided x-ray shows tooth #15 with occlusal and distal caries along with an existing small occlusal pit 
amalgam restoration, involving about 25 % of the natural tooth structure. There is no periapical film to review 
to allow for an endodontic assessment of the tooth. The Plan allows for molar crowns where there is more than 
50% loss of tooth structure from decay or injury. Our reviewer found that in this instance there is substantially 
less than 50% involvement of the natural tooth structure, and no availability to assess the periapical status of 
the tooth due to insufficient x-ray views of the tooth. Given the presentation of the tooth on x-ray, there would 
be no necessity for a crown on tooth #15 due to the lack of structural damage. Our physician reviewer also 
found that the tooth is restorable with conventional restorative materials. 
 
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 the crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown (D2752) for tooth #15.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urgent care center global fee billed for date of service 
January 19, 2021, with code S9083. 
 
You asked the Plan to pay for the urgent care global fee. You say that this is a medically necessary services that 
must be paid. The Plan denied your request. The Plan says a valid Medicare code was not reported. No 
payment can be made for the billed code. 
 
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 S9083 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT code S9083 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the urgent care global fee have not been met. Therefore, we decided that the Plan does not have to 
pay for the urgent care center global fee billed for date of service January 19, 2021, with code S9083.
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. The Plan denied your request. The Plan says the enrollee 
appears to be back to her baseline. 
 
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 physician reviewer 
found the enrollee is at a supervision assist level for rolling, standing up, walking, and functional transfers. She 
is independent with hygiene, dressing, and eating. She is at moderate assist for toileting. She does not have 
documented skilled nursing or skilled therapy needs. Daily skilled services are not shown to be required to 
establish a maintenance program or to prevent deterioration of her condition. Her care needs are custodial and 
intermittent. 
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on August 6, 2021.
You asked the Plan to waive the copayment for ambulance transportation. You say that that the copayments for these transportation services are unreasonable. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for each one-way Medicare-covered ambulance ground trip service.
You been asked to pay a $250 copayment for ambulance transportation. Ambulance transportation falls within the "Ambulance Services" benefit category. This means that you have been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance transportation provided on August 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the records provided support the need for drug being 
requested. The Plan denied your request. The Plan says the record does not show that the enrollee tried one of 
the preferred drugs or that there are medical reasons preventing her from using one of them. 
 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 Euflexxa. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the enrollee has bilateral knee 
osteoarthritis. She takes Diclofenac, Gabapentin and Mobic for pain. The enrollee has not had a trial of 
Orthovisc, Synvisc or Synvisc One which are the preferred agents. There is no evidence that the Plan's required 
drugs would likely be less effective and/or likely have adverse effects for the enrollee.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI, brain (including brain stem); without contrast 
material (CPT code 70551). 
 
You asked the Plan to pre-approve the MRI. You say that the service is necessary. The Plan denied your 
request. The Plan says this does not meet the criteria for medical necessity as outlined by Medicare rules, as 
there are no new signs/symptoms to justify a repeat MRI. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our physician reviewer found 
there was a prior history of facial trauma requiring a few facial sutures for a lid laceration, but there has been 
no visual changes and the diagnosis was mild concussion of the brain of March 23, 2022, was after that fall. 
The MRI is not necessary at this time. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI, brain (including brain stem); without contrast material (CPT code 70551).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve consultation services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve consultation services. You say that this care with an OON provider is 
medically necessary. The Plan denied your request. The Plan says there are multiple in-network options to 
provide for your medical needs. 
 
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 
consultation 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 Oticon More 1 hearing aids purchased on July 16, 2021. 
 
You asked the Plan to pay for the hearing aids. You say that this was a Plan provider, and you feel that the 
benefits were not explained clearly enough to the enrollee. The Plan denied your request. The Plan says the 
requested hearing aids are not on the Plan's hearing aid formulary, and during the enrollee's appointment the 
provider reviewed different models which were on and off the formulary, and this was explained at the time of 
service. The record includes a waiver signed by the enrollee that acknowledges that the hearing aids purchased 
on this date are not covered by the Plan's copay program. 
 
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 plans coverage rules apply in this case. The Plan covers 
certain hearing aids when purchased through the Plans specified routine hearing provider. 
  
 Though the Plan offers a supplemental benefit in excess of Medicare coverage, the hearing aids requested are 
not among those covered under this benefit. The documentation includes a Device Waiver form signed by the 
enrollee which declares that the purchased devices are not on the approved list of devices through the health 
plan. Therefore, we decided that the Plan does not have to pay for the Oticon More 1 hearing aids purchased on 
July 16, 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 IRF care is medically reasonable and necessary for 
the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have 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 that the patient has a past medical history of diabetes, dyslipidemia, dysarthria, 
hyperlipidemia, and stroke and is living at home with weakness. Medical problems are stable.  There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. In conclusion, 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on 
December 1, 2021. 
 
You asked the Plan to waive the coinsurance for Part B drugs. You say that the injection cost is excessive. The 
Plan denied your request. The Plan says the coinsurance applied is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Part B drugs obtained in an in-network provider's office or outpatient setting. The allowed 
amount of the claim is $1,033.50, resulting in a coinsurance amount of $206.70 ($1,033.50 x 20%). 
 
You have been asked to pay $206.70 for Part B drugs. Part B drugs fall within the Medicare Part B Prescription 
Drugs benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided 
on December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no swelling of the chest, trunk, or abdomen. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found based on the medical records provided, there is no documentation that the enrollee has lymphedema of 
the chest, trunk or abdomen. The provided medical records only document edema of the lower extremities. 
There is no documentation to indicate the segmented pump over a standard pump. The provided records do not 
document an adequate trial and failure of the standard pump. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0652, E0667) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane. 
 
You asked the Plan to pre-approve Durolane. You say that the records provided support the need for the drug 
requested. The Plan denied your request. The Plan says the preferred formulary drug needs to be tried and 
failed first to meet step therapy criteria. 
 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 Durolane. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the record indicates that the enrollee has 
osteoarthritis of knee. The requested medication is a new start. The provided records do not indicate that the 
enrollee has tried and failed the Plan's preferred step one alternative. The record does not indicate that the 
enrollee has a contraindication to or would have an adverse effect from the Plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the total electric hospital bed (CPT code E0265). 
 
You asked the Plan to pre-approve the total electric hospital bed. You say that this fully electric hospital bed 
with full side rails is medically necessary. The Plan denied your request. The Plan says this item is not covered 
by Medicare or the health plan. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the total electric hospital bed have not been met. The Medicare 
rules say that a total electric hospital bed (E0265) is not covered. Total electric beds will be denied as not 
reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve the total electric 
hospital bed (CPT code E0265).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the limited oral evaluation (D0140) and periapical x-rays (D0220) 
provided on December 1, 2021. 
 
You asked the Plan to pay for the limited oral evaluation and periapical x-rays. You say that you would like 
reconsideration because you did not authorize these services. The Plan denied your request. The Plan says that 
you have exhausted your benefit for the x-rays and the limited oral evaluation is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers oral exams 
and periapical x-rays once per calendar year.  
 
We looked at your request, the file, and Medicare rules. Based on this information, we decided that the Plan's 
rules for coverage of the limited oral evaluation and periapical x-rays have been met. Specifically, you were 
referred for the limited oral evaluation by a contract provider. The file does not show that the Plan provided 
notice that the limited oral evaluation would not be covered. Under Medicare rules, this means the limited oral 
evaluation is considered approved by the Plan. Additionally, the Plan has not forwarded any evidence to 
support that you have exhausted your benefit for periapical x-rays. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the limited oral evaluation (D0140) and 
periapical x-rays (D0220) provided on December 1, 2021.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee can no longer walk or use their hands, 
but the doctors are not giving a valid reason the as to why they cannot use their limbs. The Plan denied your 
request. The Plan says the stay is not medically necessary based on SNF criteria. 
 
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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee has stabilized medically and is 
ready for discharge from the hospital.  The enrollee does not require skilled nursing and/or skilled therapy 
services on a daily basis. The enrollee is medically stable and can receive further rehabilitation services at a 
lower level of care. Although further rehabilitation services would be appropriate to improve function, as a 
practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The 
enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The 
enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's 
physical function is at or near their baseline and they can receive services at a lower level of care. Admission to 
a SNF for inpatient skilled rehabilitation services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.