Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Simponia Aria. 
 
You asked the Plan to pre-approve Simponia Aria. You say that this drug is medically reasonable and 
necessary. 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 Simponia Aria. Our reviewer says that 
the requested drug is not medically reasonable and necessary. Our physician reviewer found the Plan requires a 
trial of Humira, Enbrel, Xeljanz, or Rinvoq 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 Simponia Aria have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Simponia Aria.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on March 15, 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 were not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.   
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on March 15, 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 enrollee needs ongoing treatment to prevent 
deconditioning. The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient 
Rehabilitation setting 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 the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that 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. Our 
physician reviewer also found that 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: 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 any other inpatient setting will not provide the acute 
care needs of this enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for 
IRF services. 
 
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 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. While the 
enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an 
intensive rehabilitation 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 limited oral evaluation (D0140), the first periapical x-ray 
(D0220), and each additional periapical x-ray (D0230) provided by an out-of-network provider on November 
24, 2021. 
 
You asked the Plan to pay for the limited oral evaluation (D0140), the first periapical x-ray (D0220), and each 
additional periapical x-ray (D0230). You say that you went to the dentist you wanted to see. You say you have 
been with that dentist for almost 20 years. The Plan denied your request. The Plan says you do not have out-of-
network 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 limited oral evaluation (D0140), 
the first periapical x-ray (D0220), and each additional periapical x-ray (D0230) are not among those covered 
under this benefit. The record shows that the dentist was out-of-network. Therefore, we decided that the Plan 
does not have to pay for the limited oral evaluation (D0140), the first periapical x-ray (D0220), and each 
additional periapical x-ray (D0230) provided by an out-of-network provider on November 24, 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 requested continuation of IRF care is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued IRF 
care. 
 
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 
enrollee does not meet criteria for continued IRF care. Our physician reviewer found 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 was admitted for cervical spine surgery. Medical 
problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on February 24, 
2022, and a limited oral evaluation (D0140) provided on March 15, 2022. 
 
You asked the Plan to pay for periodontal maintenance and an evaluation. You say that you went with this 
insurance specifically for the denial coverage. The Plan denied your request. The Plan says periodontal 
maintenance (D4910) and a limited oral evaluation (D0140) are not covered by your routine 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 pay for 
periodontal maintenance (D4910) provided on February 24, 2022, and a limited oral evaluation (D0140) 
provided on March 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office visit with intravenous therapy to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the office visit with intravenous therapy. You say that you have a systemic 
autoimmune disease, and you need to see this out-of-network provider. The Plan denied your request. The Plan 
says the provider is out-of-network and therefore, the services 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 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 office visit with intravenous therapy. We found no exception that would require 
the Plan to pre-approve the office visit with intravenous therapy. The records provided for review do not show 
that the services at issue are urgent or emergent. Therefore, we decided that the Plan does not have to pre-
approve the office visit with intravenous therapy 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 a panoramic radiographic image (D0330) provided on March 
31, 2022. 
 
You asked the Plan to pay for a panoramic radiographic image. You say that you were unaware certain x-rays 
are offered for different times and you cannot afford this payment. The Plan denied your request. The Plan says 
this service is allowed one time every thirty-six months, and the records show that you received this service 
less than 36 months ago (services previously performed on April 21, 2021). 
 
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, a panoramic radiographic image is 
only covered once every 36 months. The Plan paid for the  panoramic radiographic image provided on April 
21, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for a 
panoramic radiographic image (D0330) provided on March 31, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission. 
 
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 
enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 was admitted for surgical repair of a hip fracture and was transferred to skilled nursing on June 
23, 2022. Medical problems are stable. There are no complex nursing or rehabilitation needs.  
 
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or 
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical dental extraction (CPT code 41899). 
 
You asked the Plan to pre-approve the surgical dental extraction. You say that you have been suffering from 
pain and discomfort for approximately more than 20 days, you have an infection in the mouth-piece that may 
cause greater and serious complications and it cannot be done in the simple way. The Plan denied your request. 
The Plan says the requested dental service is not covered under the Health Plans supplemental dental benefit 
and is not covered by Medicare. 
 
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 supplemental dental 
benefit does not cover surgical dental extractions. The health plan contract says that up to four (4) extractions 
are covered every year (simple). Therefore, we decided that the Plan does not have to pre-approve the surgical 
dental extraction (CPT code 41899).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a second diagnostic facet joint injection procedure. 
 
You asked the Plan to pre-approve a second diagnostic facet joint injection procedure. You say that this second 
injection is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The 
Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that a second diagnostic facet joint procedure will be 
considered medically reasonable and necessary when there is a consistent positive response of at least 80% 
relief of primary (index) pain. 
 
We looked at the file and Medicare rules. In this case, the documentation submitted indicates that there was only a 50% improvement in pain following the first diagnostic injection. Based on this information, we decided 
that Medicare rules for coverage of a second diagnostic facet joint injection procedure have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a second diagnostic facet joint injection 
procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling (D4346) and medications dispensed in-office for 
home use (D9630) provided by a network provider on January 25, 2022. 
 
You asked the Plan to pay for the scaling (D4346) and the medications dispensed in-office for home use 
(D9630). You say that these services should be covered. The Plan denied your request. The Plan says the 
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 Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the scaling (D4346) and medications 
dispensed in-office for home use (D9630) are not among those covered under this benefit. The record shows 
the periodontic codes that are covered include D4355, D4341, D4342, and D4910. Therefore, we decided that 
the Plan does not have to pay for the scaling (D4346) and medications dispensed in-office for home use 
(D9630) provided by a network provider on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full amount for a crown - porcelain/ceramic (dental code 
D2740) for tooth #18 provided on February 2, 2022. 
 
You asked the Plan to pay the full amount for a crown - porcelain/ceramic. You say that the dentist advised you 
on what crown to get but never told you it would not be covered by the Plan. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. Your contract with the Plan clearly says that 
you must pay 50% coinsurance and a $100 deductible for Class 3 Major Services. The Plan also says that the 
crown was paid at the allowed amount of a metal crown, as this would be the least costly method of treatment. 
 
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 Plan processed the crown  
porcelain/ceramic at the least costly method of a metal crown. 
 
The record shows the Plan paid their share of your crown under code D2751, which is a metal crown. You have 
been asked to pay $582.50 for the crown  porcelain/ceramic for tooth #18. This means 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 pay the full 
amount for a crown - porcelain/ceramic (dental code D2740) for tooth #18 provided on February 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Comprehensive Oral Evaluation on February 14, 2022. 
 
You asked the Plan to pay for Comprehensive Oral Evaluation. You say that you would like to appeal the 
denial of the claim. The Plan denied your request. The Plan says it was determined that a comprehensive oral 
evaluation was rendered in the past 36 months, therefore, we are unable to cover the comprehensive oral 
evaluation. 
 
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 
Comprehensive Oral Evaluation on February 14, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation therapy with laser ablation of 
varicose veins in the lower extremities. 
 
You asked the Plan to pre-approve endovenous ablation therapy with laser ablation of varicose veins in the 
lower extremities. You say that these services are medically reasonable and necessary. The Plan denied your 
request. The Plan says the clinical indications for the requested radiofrequency ablation services have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules say that ablation therapy is subject to the criteria listed 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 endovenous ablation therapy with laser 
ablation of varicose veins in the lower extremities. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found that the 
documentation does not meet criteria and does not support the medical necessity of the 4 venous ablation 
treatments requested.  The documentation only focuses on the left leg.  There is no documentation of issues 
with the right leg. With respect to the left leg, no significant reflux is demonstrated throughout the length of the 
small saphenous vein and therefore ablation of this vessel cannot be covered. A nonhealing ulcer is noted on 
the lateral leg. There is insufficient documentation that the ulcer is in the territory of the great saphenous vein 
(medial). The photograph provided does not satisfactorily demonstrate a venous stasis ulcer.  Furthermore, in a 
patient with diabetes, hypertension, hyperlipidemia, atrial fibrillation, and history of liver transplant, the 
documentation is not sufficient to ascribe the ulcer to venous disease without more objective information, 
particularly information regarding arterial perfusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of endovenous ablation therapy with laser ablation of varicose veins in the lower 
extremities have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous 
ablation therapy with laser ablation of varicose veins in the lower extremities.