Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve thirty (30) additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional trips. You say that the additional trips are necessary. The Plan 
denied your request. The Plan says you currently have 30 trips remaining and you will have exceeded your 
benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. The 49th trip and beyond is not a covered benefit. Your request exceeds your benefit. Your 2023 EOC states up to 48 one-way trips are covered 
each year (limited to ground transportation only). Therefore, we decided that the Plan does not have to pre-
approve thirty (30) additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination and a determination of refractive 
state (92015) provided on October 12, 2022. 
 
You asked the Plan to pay for a medical eye examination and a determination of refractive state (92015). You 
say that you have gone to the provider before and never had any issues with it being covered in the past. The 
Plan denied your request. The Plan says per your 2022 EOC, there is a $30 copayment per visit to an 
ophthalmologist or optometrist for Medicare-covered vision care. The Plan also says that you also had a 
determination of refractive state (92015) provided by a provider who is not a vision provider in the Plan 
network. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers the eye refractions when the eye refractions are part of a routine eye examination and 
with a Plan vision provider. 
 
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 $30 
copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care. 
 
We looked at the file and the Plan's rules. You have been asked to pay a $30 copayment for a medical eye 
examination. Medical eye examinations fall under a visit to an ophthalmologist or optometrist for Medicare-
covered vision care benefit category. This means that you have been asked to pay the correct amount for the 
medical eye examination based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan.  
 
The Plan rules also say Original Medicare does not cover routine eye examinations (eye refractions) for 
eyeglasses/contacts. The Plan rules also say that routine vision service including routine non-medical eye 
examinations are covered through a Plan vision provider. The record shows this was a medical eye examination 
and eye refraction and not routine. The record also shows that the provider who provided the services is not a 
Plan vision provider. Based on this information, we decided that the Plan's rules for coverage of a medical eye 
examination and a determination of refractive state (92015) have not been met. Therefore, we decided that the 
Plan does not have to pay for a medical eye examination and a determination of refractive state (92015) 
provided on October 12, 2022.
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 continued SNF care is medically necessary. The 
Plan denied your request. The Plan says that SNF care is no longer medically necessary. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee can continue with repetitive exercise and support from non-skilled 
personnel. Daily skilled nursing and skilled therapy services are 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.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intravitreal injection of a pharmacologic agent 
(67028) and the injection of faricimab-svoa (J2777). 
 
You asked the Plan to pre-approve an intravitreal injection of a pharmacologic agent (67028) and the injection 
of faricimab-svoa (J2777). You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says the information provided on appeal does not include the visual acuity which is a 
required element of the guideline and must be documented in the medical record. 
 
The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 intravitreal injection of a 
pharmacologic agent (67028) and the injection of faricimab-svoa (J2777). Our reviewer says that the criteria 
for coverage of this drug and service have not been met. Our physician reviewer found exam features such as 
visual acuity is not documented for this service. Our physician reviewer also found that there is no 
documentation that the enrollee has failed treatment with Intravitreal Avastin injections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of intravitreal injection of a pharmacologic agent (67028) and the injection of 
faricimab-svoa (J2777) have not been met. Therefore, we decided that the Plan does not have to pre-approve an 
intravitreal injection of a pharmacologic agent (67028) and the injection of faricimab-svoa (J2777).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to approve this. The Plan 
denied your request. The Plan says the medical criteria for a CGM have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their 
treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this 
information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #8. 
 
You asked the Plan to pre-approve a crown. You say that your current crown does not look good anymore. The 
Plan denied your request. The Plan says aesthetic procedures 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. The Plan covers a crown when 
the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of a crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
crown (D2740) for tooth #8.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a pontic (D6245), and a retainer crown (D6740). 
 
You asked the Plan to pre-approve a pontic and a retainer crown. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that these services are not medically necessary. 
 
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 pontic and a 
retainer 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 a pontic and a retainer crown. Our 
physician reviewer found the documentation provided meets the criteria for a replacement fixed bridge 
replacing missing tooth #14 with a pontic (D6245) using teeth #'s 13 and 15 as abutment retainers (D6740). 
 
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 pontic and a retainer crown have been met. Therefore, we decided that the 
Plan has to pre-approve a pontic (D6245), and a retainer crown (D6740).  
 
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: 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 you require an IRF level of care due to your current 
medical needs. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements for approval. 
 
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 you do not require treatment by multiple therapies, including either physical 
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a 
different 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: 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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 there is no documentation provided indicating medical necessity for admission toa 
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not 
require services at the LTACH that are not available at the acute care hospital where the enrollee is currently 
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at 
the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, 
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and 
effectively only on an inpatient basis. 
 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pancreatectomy, proximal subtotal with total 
duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); 
with pancreatojejunostomy (48150), pancreatectomy, proximal subtotal with total duodenectomy, partial 
gastrectomy, choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); without 
pancreatojejunostomy (48152), colectomy, partial; with resection, with colostomy or ileostomy and creation of 
mucofistula (44144) to be provided by out-of-network providers. 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the requested surgical procedures are medically necessary; however, the 
requested surgical procedures performed out-of-network is 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 provider at issue in this case is not a network provider with the Plan. 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 physician reviewer found the review has determined that 
the services are not necessary to be performed out of network. The enrollee can receive the services in-network. 
 
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.  
 
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 the services. Therefore, we decided that the Plan does 
not have to pre-approve pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, 
choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); with pancreatojejunostomy (48150), 
pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and 
gastrojejunostomy (Whipple-type procedure); without pancreatojejunostomy (48152), colectomy, partial; with 
resection, with colostomy or ileostomy and creation of mucofistula (44144) to be provided by out-of-network 
providers.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944). 
 
You asked the Plan to pay for an occlusal guard. You say that you need this because you clench your teeth. The 
Plan denied your request. The Plan says this mouth guard has been correctly denied. 
 
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 an 
occlusal guard (D9944).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity Modulated Radiation Therapy (IMRT) (77014, 
G6002, G6015). 
 
You asked the Plan to pre-approve IMRT. You say that the requested therapy is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the request does not meet the Medicare or 
health plan coverage criteria. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the case file does not include a treatment plans comparison (that the insurer specifically 
requested to justify necessity). Thus, no records show that a 3D conformal radiation cannot meet accepted 
dosimetric constraints. There is no rationale provided for the need for IMRT in the case file. IMRT will almost 
always reduce the dose to critical structures, the relevant question is to what extent it does so and is that 
reduction clinically meaningful to reduce toxicity risks. However, the case records did adequately demonstrate 
the need for IMRT using plausible dosimetric evidence (i.e., to what extent IMRT reduced the dose-volume 
exposure of critical normal tissues). This is important in justifying the need for IMRT in clinical scenarios 
(such as this case) for which IMRT is not standard. Simply asserting that IMRT is necessary does not constitute 
sufficient documentation for medical necessity of IMRT. As such, I would not think that IMRT would be 
considered to be furnished in accordance with accepted standards or care. The LCD describe those pelvic 
cancers "may support the use of IMRT" though demonstrating a dosimetric benefit is required. The decision is 
unfavorable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intensity Modulated Radiation Therapy (IMRT) (77014, G6002, G6015).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intensity-Modulated Radiation Therapy (IMRT) 
(G6017, G6015, 77386, G6002, 77014). 
 You asked the Plan to pre-approve IMRT. You say that IMRT is particularly useful for obtaining the highly 
conformal dose distributions needed to irradiate complex targets positioned near, or immediately adjacent to, 
sensitive normal tissues. IMRT is medically necessary for the enrollee. The Plan denied your request. The Plan 
says the request does not meet the Medicare or health plan coverage criteria. 
 
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 IMRT. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found a more protracted 6-10-fraction approach would be a standard alternative for enrollees with 
central or ultra-central lung tumors for which SBRT might be associated with unacceptable risks of toxicity. 
This enrollees tumor is central. When opting conventional fractionation, IMRT could be considered 
medically necessary with dosimetric justification as supported by consensus guidelines and published literature. 
For this case, no dosimetric justification is provided and it is not plausible that accepted dosimetric constraints 
could not be met, as the treatment for early-stage NSCLC does not incorporate mediastinal lymph nodes, 
whereby IMRT would be needed to spare the esophagus, spinal cord and lungs. Also, for this case, the basis for 
denial was insufficient documentation of need for IMRT with dosimetric justification, which is generally 
needed for those cases for which IMRT is not an accepted standard of care. The decision is unfavorable.  It 
would be favorable for 35 fractions of 3D conformal radiation with IGRT or 10 fractions of IMRT. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intensity-Modulated Radiation Therapy (IMRT) (G6017, G6015, 77386, G6002, 77014).