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

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing in the right upper 
and lower quadrants (D4341). 
 
You asked the Plan to pre-approve periodontal scaling. You say that there are concerning areas around three 
teeth in the upper quadrant. The Plan denied your request. The Plan says there is no significant bone loss. 
 
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 periodontal 
scaling 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 periodontal scaling. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that in this instance there are an 
insufficient number of teeth in the upper arch to qualify for periodontal scaling and root planing with only tooth 
#3 and #4 having any signs of a notable amount of bone loss.  There are no clearly affected teeth in the right 
lower arch.  Given the Plans criteria, the request for periodontal scaling for upper and lower right quadrants would not meet Plan criteria. 
 
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 periodontal scaling have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planing in the right upper and lower quadrants (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for injections provided on April 25, 2022. 
 
You asked the Plan to waive the cost for injections. You say that the cost of these injections is too high and 
should be lowered. The Plan denied your request. The Plan says the cost was applied correctly for these 
services. 
 
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 $50 
copayment for a specialist, and a 20% coinsurance for Medicare Part B drugs. The allowed amount of this drug 
is $154.75, resulting in a coinsurance amount of $30.95 ($154.75 x 20% = $30.95). ($30.95 coinsurance + $50 
copayment = $80.95 total). 
 
You have been asked to pay $80.95 for injections. Injections falls within the Medicare Part B Drugs and 
Physician/Practitioner services 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 cost for injections provided on April 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost for lab services and cardiac tests provided from 
February 24, 2022, to February 28, 2022. 
 
You asked the Plan to waive the cost for lab services and cardiac tests. You say that you feel you were misled 
and lied to about the cost of these services. The Plan denied your request. The Plan says the cost share applied 
was 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 $750 
for certain services and a $200 copayment for outpatient hospital services.  
 
You have been asked to pay the allowed amount of $934.35, which is less than the $950 for lab services and 
cardiac tests ($76.41 + $10 + $637.94 + $200 + $10 = $934.35). Lab services and cardiac tests fall within the 
Outpatient Hospital Services 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 cost for lab services and cardiac tests provided from February 
24, 2022, to February 28, 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 SNF care is medically necessary. The Plan denied 
your request. The Plan says based on Medicare guidelines, the SNF services do not meet the requirements for 
approval. 
 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 from a nursing perspective, the enrollee received oral medications and insulin. The 
enrollee had stable vital signs. The enrollees lungs were clear. Regarding rehabilitation services, the enrollee 
received physical therapy (PT), speech therapy (ST) and occupational therapy (OT). The enrollee was at a 
maximal to total assist level for functional mobility and required a mechanical lift for transfers. The enrollee 
required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. 
There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy 
services on a daily basis. As a practical matter, this enrollee does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the Plan denied my authorization for inpatient 
rehabilitation. You say that you want authorization for inpatient rehabilitation. The Plan denied your request. 
The Plan says based on Medicare guidelines the inpatient rehabilitation facility services you are requesting 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 you were admitted for anemia, sacral decubitus ulcer, and a urinary tract infection. Medical problems are stable. There are no complex nursing or rehabilitation needs. While you have a need for 
physical 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
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 pain related to right 
knee osteoarthritis. She has not tried and failed the Plan's required drugs, Orthovisc, Synvisc, and Synvisc-One. 
The records do not show that the required drugs would be contraindicated or less effective; therefore, Monovisc 
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 Monovisc.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rituximab. 
 
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 services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has chronic inflammatory 
demyelinating polyneuritis. Based on the medical records provided and the Medicare-approved major drug 
compendia there is no documentation that the Rituximab at issue in this case meets Medicare criteria for 
medically reasonable and necessary. The Medicare-approved major drug compendia contain no citation 
indicating that chronic inflammatory demyelinating polyneuritis is a medically-accepted indication for use of 
Rituximab. 
 
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 Rituximab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist telehealth visit provided on 
August 5, 2021. 
 
You asked the Plan to waive the copayment for the specialist telehealth visit. You say that the phone call was 
only a prescription renewal and you did not speak to an actual specialist. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing amount. 
 
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 $40 
copayment for specialist telehealth services.  
 
You have been asked to pay a $40 copayment for the specialist telehealth visit. The specialist telehealth visit 
falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 copayment for a specialist telehealth visit provided on August 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive or reduce the copayment for ambulance transportation 
provided on May 13, 2022. 
 
You asked the Plan to waive or reduce the copayment for the ambulance transportation. You say that the 
copayment is too much for a short trip. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $225 
copayment for each one-way ambulance trip.  
 
You have been asked to pay a $225 copayment for the ambulance transportation. The ambulance transportation 
falls within the Ambulance Services 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 or reduce the 
copayment for ambulance transportation provided on May 13, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a hemodialysis procedure with a physician 
provided on February 25, 2022. 
 
You asked the Plan to waive the copayment for a hemodialysis procedure. You say that your dialysis 
treatments should be covered in full, without a coinsurance. The Plan denied your request. The Plan says the 
coinsurance applied was 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 Services to Treat Kidney Disease. The allowed amount of this item is $71.69, resulting in a 
coinsurance amount of $14.34 ($71.69 x 20% = $14.34). 
 
You have been asked to pay a $14.34 coinsurance for a hemodialysis procedure. A hemodialysis procedure 
falls within the Services to Treat Kidney Disease 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 
copayment for a hemodialysis procedure with a physician provided on February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the requested epidural steroid 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested epidural steroid injection. 
 
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 an epidural steroid injection. Our 
reviewer says that the enrollee does not meet criteria for the requested epidural steroid injection. Our physician 
reviewer found the enrollee has a diagnosis of Radiculopathy in the lumbar region. The enrollee has undergone 
previous lumbar laminectomy. On August 16, 2022, it is documented that the enrollee was "having continuance 
of symptoms but did say she had 90% pain relief after her Interlaminar epidural steroid injections (ILESIs) at 
L2-L3." The enrollee reported a pain range in the previous week of 6/10 to 9/10. The documentation in the 
medical record does not support that the enrollee had at least 50% sustained improvement in pain relief from 
the previous injection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection.
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 are appealing the denial of the IRF care. 
 The Plan denied your request. The Plan says authorization because the IRF care is not medically necessary, 
and your needs can be met at a lower level of care such as a skilled nursing facility (SNF). 
 
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 your medical problems are stable, and there are no complex nursing or rehabilitation needs. 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 
and/or occupational therapy, there is no documented need for intensive rehabilitation 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 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says you do 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 you do 
not meet criteria for IRF admission. Our physician reviewer found based on the limited documentation 
provided, you do not require the intensity of services provided at an IRF.  Specifically, you are not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for office visits provided from March 9, 2022, 
to April 11, 2022. 
 
You asked the Plan to waive the copayments for the office visits. You say that these visits should be included 
as part of your chemotherapy treatment. The Plan denied your request. The Plan says you have been charged 
the correct cost sharing amount. 
 
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 for each specialist visit and a $20 copayment for each primary care visit.  
 
The file shows you had a total of 10 specialist visits and 1 primary care visit from March 9, 2022, to April 11, 
2022. Therefore, you have been asked to pay a $30 copayment for each specialist visit and a $20 copayment for 
the primary care visit, for a total of $320. The office visits fall within the Physician/Practitioner Services, 
Including Doctor's Office Visits 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 copayments for 
office visits provided from March 9, 2022, to April 11, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says the enrollee is covered for up to 10 one-
way transportation trips every year and additional trips will not be approved. 
 
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. The Plan covers a maximum of 10 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
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 age-related 
osteoporosis/postmenopausal osteoporosis. She has not tried and failed the Plan's required drug, zoledronic 
acid. The records do not show that the required drug would be contraindicated or less effective; therefore, 
Prolia 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 Prolia.