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

 
We decided that the Plan does not have to pre-approve two prefabricated abutments (D6056 x2) and two 
implant supported porcelain/ceramic crowns (D6065 x2). 
 
You asked the Plan to pre-approve the prefabricated abutments and implant supported porcelain/ceramic 
crowns. You say that you have implants on one side, but not the other and only has the screws. 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 two 
prefabricated abutments (D6056 x2) and two implant supported porcelain/ceramic crowns (D6065 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).  
You asked the Plan to pre-approve RFA. The Plan denied your request. The Plan says based on this 
information, we're denying your appeal because according to the clinical criteria and LCD, the clinical 
documentation must demonstrate the member received at least 80% pain relief and duration of relief from the 
second diagnostic facet medial branch blocks (MBB), lower back injections. The clinical documentation 
provided on the appeal shows that the amount of pain relief the member received was 50% from the second set 
of lumbar injections which were rendered on March 4, 2022. 
 
The Plan follows Medicare rules. Medicare rules say that after the first diagnostic facet joint procedure, there 
must be a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief 
being consistent with the agent used). 
 
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 RFA. Our reviewer says that RFA is 
not medically necessary. Our physician reviewer found only two levels of RFA per session is allowed. The 
enrollee only received 50% pain relief from the second set of diagnostic MBBs. Therefore, the request doesn't 
meet LCD criteria and the request is deemed 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 RFA have not been met. Therefore, we decided that the Plan does not have to 
pre-approve radiofrequency ablation (RFA).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis. 
 
You asked the Plan to pre-approve Renflexis. The Plan denied your request. The Plan says the enrollee has not 
tried and failed Remicade, Inflectra, Infliximab, or Simponi Aria. 
 
 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 Renflexis. Our physician reviewer 
found that the record indicates the enrollee has rheumatoid arthritis. The requested medication is a new start. 
The Plan requires a trial of Remicade, Inflectra, Infliximab, or Simponi Aria before they will approve the 
requested drug. 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 Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Renflexis.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve metabolic positron emission tomography (PET) scan for 
the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the request cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 scan. Our reviewer says that the 
requested scan is not medically resaonable or necessary. Our physician reviewer found the records provided 
suggest possible Alzheimer's disease (AD) versus a vascular dementia. There was no indication that fronto-
temporal dementia (FTD) was suspected. The records also did not support that diagnostic criteria for both AD 
and FTD were met. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve metabolic positron emission tomography (PET) scan for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056), and an abutment 
supported porcelain fused to a crown (D6060) to be provided by a participating provider. 
 
You asked the Plan to pre-approve a prefabricated abutment and an abutment supported porcelain fused to a 
crown. You say that you are in the middle of the denture process. The Plan denied your request. The Plan says 
D6056 and D6060 are not covered dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated abutment (D6056), and an abutment supported porcelain fused to a crown (D6060) to be provided 
by a participating provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 8, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aranesp. 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has anemia associated with 
cancer while on chemotherapy. He has not tried and failed the Plan's required drugs, Retacrit or Procrit. The 
records do not show that the required drugs would be contraindicated or less effective; therefore, Aranesp is not 
reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical pathology rendered on December 22, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Plans must disclose all supplemental benefit 
information.  
 
 We looked at the file and the Plans rules. The file shows that you requested reimbursement through the Plans 
Pick your perks benefit for surgical pathology lab work. This is not a benefit that is covered by the 
supplemental benefit. Based on this information, we decided that Plans rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology 
rendered on December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic service (97810), provided on November 4, 
2021. 
 
You asked the Plan to pay for the chiropractic service. You say that the service is medically necessary. The 
Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic service (97810), provided on November 4, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve Botox. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says step therapy criteria have not been met. 
 
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 Botox. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Dysport or Xeomin before they will approve the requested drug. In this case, the patient has not tried 
and failed the required drug(s). There is no documentation provided indicating that the plans required drug(s) 
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 Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Botox.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve the oncology services provided at the in-network benefit level by 
an out-of-network provider. 
 
You asked the Plan to pre-approve the oncology services. You say that the closest in-network provider is over 
100 miles away from your residence and the out-of-network provider is half the distance. The Plan denied your 
request. The Plan says that the enrollee can use the out-of-network provider at the out-of-network benefit level. 
The Plan also says in-network providers are available. 
 
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is 
considered accessible to an enrollee if contract providers are available within reasonable distance and travel 
time from the enrollees home. The Plan says that enrollees must use contract providers.  
 
The provider is a non-contract provider. We were able to confirm that the Plan does not have contract providers 
located within reasonable distance and travel time from your home who can provide the radiation oncology. 
Under Medicare rules, this means that contract providers are not accessible to you. Therefore, we decided that 
the Plan has to pre-approve the oncology services provided at the in-network benefit level by an out-of-network 
provider.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Boa Click socket system and prosthetic skin care 
lotion for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the clinical progress note written by the physician does not state the medical necessity 
for the requested item and does not corroborate the information presented in the prosthetist document. 
 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 services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested lotion cannot be considered durable medical equipment as it cannot withstand repeated use. 
The health plan has approved a socket replacement. The Boa Click socket has not been shown to be superior to 
other standard treatments for the medical condition. 
 
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 a Boa Click socket system and prosthetic skin care lotion for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Replacement, mitral valve, with cardiopulmonary 
bypass (33430), comprehensive electrophysiologic evaluation (93656), Echocardiography (93312) and 
inpatient hospital admission for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that records show the enrollee does not have severe mitral 
regurgitation. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The documentation 
does not suggest that the mitral valve disease is of sufficient severity to warrant valve replacement. Our 
physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Replacement, mitral valve, with cardiopulmonary bypass (33430), comprehensive 
electrophysiologic evaluation (93656), Echocardiography (93312) and inpatient hospital admission for the 
enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgery provided on November 12, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the surgery. You say that the service was medically necessary. The Plan denied 
your request. The Plan says prior authorization must be obtained for non-emergent services performed by an 
out-of-network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the surgery provided on November 12, 2021 by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on 
December 2, 2021. 
 
You asked the Plan to pay for the moderate sedation services (99153). You say that the radiology reports 
should be reviewed, and the claim processed for payment. The Plan denied your request. The Plan says 
payment for this service is included in payment to the facility and not separately reimbursable.  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 99153 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List 
separately in addition to code for primary service) . 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a 
technical component only code and the claim indicate that this service was rendered in a facility setting. Based 
on this information, we decided that Medicare rules for coverage of the moderate sedation services (99153) 
have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services 
(99153) provided on December 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300). 
 
You asked the Plan to pre-approve a power seat elevation system. You say that you are appealing the denial of 
the power seat elevation system. The Plan denied your request. The Plan says this feature is not primarily 
medical in nature and is not covered 
 
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 a power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a power seat elevation system (E2300).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical value and effectiveness of Keytruda for the treatment of peritoneal 
mesothelioma has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for 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 Keytruda. Our reviewer says that 
Keytruda is not medically reasonable and necessary. Keytruda is not FDA approved, compendia based, or 
literature supported for peritoneal mesothelioma. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of Keytruda. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction (D7210) to be performed by an oral 
surgeon. 
 
You asked the Plan to pre-approve the dental service. You say that you have a filling that broke. You say that 
you though you would be able to get it filled. You say that your dentist advised you needed to have your tooth 
extracted by an oral surgeon. You also say that your general dentist does not want to do the extraction because 
of the medication you are on. The Plan denied your request. The Plan says services must be performed by a 
participating general dentist. The Plan also says that dental services performed by an oral surgeon are not 
covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, services must be performed by a 
participating general dentist. Dental services performed by an oral surgeon are not covered. Therefore, we 
decided that the Plan does not have to pre-approve a surgical extraction (D7210) to be performed by an oral 
surgeon.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 22, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a 
covered screening test.  
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this 
testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab 
services provided on June 22, 2021.