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

 
We decided that the Plan does not have to pre-approve Jardiance. 
 
You asked the Plan to pre-approve Jardiance. The Plan denied your request. The Plan says this drug is not 
eligible for coverage under the Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Jardiance.  
 
 
 Benefits for Jardiance may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the evaluation and surgery services to be provided by an 
out-of-network provider. 
 
You asked the Plan to pre-approve the out of-network services. You say that the services are necessary. The 
Plan denied your request. The Plan says there are in-network providers that can provide the services. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the evaluation and surgery services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept procedure for the enrollee's back pain 
(CPT code 64628). 
 
You asked the Plan to pre-approve the service. You say that this procedure fills a treatment gap for those 
patients that do not receive adequate relief from traditional conservative methods and do not have instability to 
indicate fusion is the appropriate treatment. The Plan denied your request. The Plan says unproven and not 
medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the intracept procedure for the enrollee's back pain (CPT code 64628).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on June 4, 2021. 
 
You asked the Plan to pay for the medical services. You say that the patient was in the hospital on the date of 
service in question, so this claim should be paid. The Plan denied your request. The Plan says Original 
Medicare is responsible for this claim. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 1, 2021. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for medical services provided 
on June 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on December 2, 2021. 
 
You asked the Plan to pay more for the dental services. You say that you believe your dental insurance should 
have paid more for these services. The Plan denied your request. The Plan says you exhausted your dental 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  According to the Plan's rules, 
you have a $2000 annual allowance for dental services. On November 16, 2021, the Plan paid $366.00 towards 
dental services you received.  On December 2, 2021, the Plan paid $1634.00 towards dental services you 
received. This brings the total the Plan paid for dental services to $2000, which is your annual allowance. The 
Plan cannot be obligated to pay more than this annual allowance based on your Evidence of Coverage. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on December 2, 
2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Eylea (J0178). 
 
You asked the Plan to pre-approve Eylea. You say that you do not prescribe Avastin. You also say that the 
requested drug is medically necessary. The Plan denied your request. The Plan says that the enrollee has not 
tried and failed the preferred drug, Avastin. 
 
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 Eylea. Our reviewer says that the step 
therapy criteria have been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug, Avastin. The reviewer also found that the 
documentation by the provider supports that Avastin is more likely to have adverse effects for the enrollee in 
this case. Therefore, the reviewer found that the step therapy criteria have been 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 Eylea have been met. Therefore, we decided that the Plan has to pre-approve 
Eylea (J0178).  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Procrit (J0885). 
 
You asked the Plan to pay for Procrit. You say that the requested drug is medically necessary. The Plan denied 
your request. The Plan says the requested drug is 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 pay for Procrit. Our reviewer says that the requested 
drug is not medically necessary. Our physician reviewer found the provided documentation indicates the 
enrollee's iron deficiency on a laboratory report of April 28, 2022, with no iron replacement since 2019. 
Therefore, the reviewer found that the requested drug is not medically reasonable or necessary 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 Procrit have not been met. Therefore, we decided that the Plan does not have to 
pay for Procrit (J0885).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the heart with 
evaluation of blood vessel calcium. 
 
You asked the Plan to pre-approve the CT scan services. You say that this is medically necessary The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered 
service and will be denied as not medically necessary. Based on this information, we decided that Medicare 
rules for coverage of the CT scan services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the computed tomography (CT) scan of the heart with evaluation of blood vessel calcium.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cardiac risk assessment genetic screening testing provided to 
the enrollee on October 25, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says all cardiovascular genetic test kits are provided to patients via mail and returned to lab via mail. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there was insufficient support made in the documentation describing how genetic testing would 
effectively lead to a significant change in treatment and overall outcome compared to standard treatment for 
this patient's conditions. Therefore, this request for cardiac risk assessment genetic screening testing will be considered 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 the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for cardiac risk assessment genetic screening testing provided to the enrollee on October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) sensor (K0553). 
 
You asked the Plan to pre-approve a CGM sensor. You say that the requested item is a medical necessity for 
you. The Plan denied your request. The Plan says rules for coverage for CGMs and related supplies 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 use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM 
sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM) sensor (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine vision services you received from an out-of-network 
provider on November 20, 2021. 
 
You asked the Plan to pay for the out-of-network routine vision services. You say that you were never told that 
you had to use an in-network provider. The Plan denied your request. The Plan says vision care you get from 
out-of-network providers is not covered. Medicare rules say that plans can require enrollees to get care from 
network providers. The contract with the Plan says that you must see an in-network vision provider to receive 
routine vision benefits. The vision provider in this case is not a network provider with the Plan. Therefore, we 
decided that the Plan does not have to pay for routine vision services you received from an out-of-network 
provider on November 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Truxima. 
 
You asked the Plan to pre-approve Truxima. You say that this drug is medically reasonable and 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 Truxima. Our reviewer says that the 
requested drug is not medically reasonable and necessary. Our physician reviewer found The Plan requires a 
trial of drugs Rituxan, Rituxan Hycela or Ruxience before they will approve the requested drug, Truxima. 
Based on the medical records provided there is no indication that the patient has tried and failed the required 
drugs. In addition, there is no indication that the plan's required drugs would likely be less effective and/or 
likely have adverse effects for the patient. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Truxima.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ocular prosthetic services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve ocular prosthetic services. You say that this care is medically necessary. The 
Plan denied your request. The Plan says there are in-network providers available to meet your care needs. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
ocular prosthetic services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for on-site (non-transport) services you received from an 
ambulance provider on September 26, 2021. 
 
You asked the Plan to pay for the non-transport ambulance services. You say that you were not transported by 
an ambulance.  You said that you were taken to the emergency room by private auto.  You also said that the 
ambulance company told you to appeal. The Plan denied your request. The Plan says non-transport ambulance 
services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on September 26, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for on-site (non-transport) services you received from 
an ambulance provider on September 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Rexulti tablets. 
 
You asked the Plan to pre-approve Rexulti tablets. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says Rexulti tablets are not covered under the enrollee's 
Medicare Part B benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Rexulti tablets.  
 
Benefits for Rexulti tablets may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia (J0897). 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the enrollee has not tried and failed the preferred drug, zoledronic acid. 
 
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 Prolia. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate 
that the enrollee has tried and failed the preferred drug, zoledronic acid. The reviewer also found that the 
documentation does not support that Prolia would likely be less effective, and/or would likely have adverse 
effects for the enrollee in this case. Therefore, the reviewer found that the step therapy criteria have not been 
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 Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Ketamine infusion services. 
 
You asked the Plan to pre-approve Ketamine infusion services. You say that this procedure is medically 
necessary for your condition. The Plan denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of Ketamine infusion services. have been 
met. In this case, the Plan has sent several requests for medical records to your provider without results. 
Without medical records, we cannot evaluate this requested service to determine medical necessity. Therefore, 
we decided that the Plan does not have to pre-approve Ketamine infusion services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foreign transaction fees from December 10, 2021, to 
December 17, 2021. 
 
You asked the Plan to pay for the foreign transaction fees. You say that you were charged these foreign 
transaction fees when you fell while in Mexico, so they should be covered. The Plan denied your request. The 
Plan says these fees are not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that no payment may be made for any expenses 
incurred for items or services except for those needed for the diagnosis and treatment of illness and injury. In 
addition, charges billed by any non-approved provider (such as physician services, facility services, etc.) are 
also non-covered.  
 
In this case, the fees in dispute are fees assessed by your credit card company and do not represent direct 
payment for services needed to treat or diagnose a condition.  Rather, these are contractual fees that your credit 
card company charges for you using their product outside of the United States.  These fees are not payable by 
Medicare or your health plan. Therefore, we decided that the Plan does not have to pay for foreign transaction 
fees from December 10, 2021, to December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic therapy and x-rays received from November 15, 
2021, to December 22, 2021. 
 
You asked the Plan to pay for the services. You say that this service was needed for a bad nerve. The Plan 
denied your request. The Plan says these services are not covered by the plan under any circumstance. 
 
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 chiropractic therapy and x-rays received from November 15, 2021, to 
December 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for assisted living facility care provided from November 1, 
2021, to November 30, 2021. 
 
You asked the Plan to pay for the assisted living facility services. You say that assisted living facility care is 
medically necessary. The Plan denied your request. The Plan says assisted living facility care is not covered. 
 
The Plan must follow Medicare rules. Medicare does not pay for custodial care.  Any institutional care that is 
below the level of care covered in a skilled nursing facility is custodial care, and this includes assisted living 
facility care. Based on this information, we decided that Medicare rules for coverage of the assisted living 
facility services have not been met. Therefore, we decided that the Plan does not have to pay for assisted living 
facility care provided from November 1, 2021, to November 30, 2021.