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

 
We decided that the Plan does not have to pre-approve an interim complete maxillary denture (D5810) and an 
interim complete mandibular denture (D5811). 
 
You asked the Plan to pre-approve the interim complete dentures. You say that you believe the temporary 
dentures should be covered because they are part of the process for placing permanent dentures. The Plan 
denied your request. The Plan says these services are not covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit.  
 
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve an interim complete maxillary denture 
(D5810) and an interim complete mandibular denture (D5811).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laboratory services provided on March 8, 
2022. 
 
You asked the Plan to waive the copayment for the lab services. You say that the tests should be covered since 
they were requested by your doctor. 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 lab services provided at an outpatient hospital.  
 
You have been asked to pay $21.39, which is less than the $40 copayment for the lab services. The lab services 
fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 laboratory services provided on March 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on February 21, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition for the drug testing performed (22+ drug classes). Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the drug testing services provided on February 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for your inpatient hospital stay from March 20, 
2022, to March 23, 2022. 
 
You asked the Plan to waive the copayment for your inpatient hospital stay from March 20, 2022, to March 23, 
2022. You say that you should not be responsible for this copayment. The Plan denied your request. The Plan 
says you are responsible to pay a $315 copayment per day for days 1-6 per hospital stay. 
 
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 $315 
copayment for Inpatient Hospital Care.  
 
You have been asked to pay a $315 copayment for your inpatient hospital stay from March 20, 2022, to March 
23, 2022. Inpatient hospital stays fall within the Inpatient Hospital Care 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 your inpatient hospital stay from March 20, 2022, to March 23, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. The Plan denied your request. The Plan says the enrollee has not 
met the step therapy criteria. 
 
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 Feraheme. Our reviewer says that 
Feraheme is not medically reasonable and necessary in this case. Our physician reviewer found that the case 
file does not contain documentation of trial and failure of Infed (iron dextran) and Venofer (iron sucrose). The 
documentation does not support that Infed and Venofer would likely be less effective, and/or would likely have 
adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the $45 copayment for an injection on November 29, 2021. 
 
You asked the Plan to waive the $45 copayment for an injection on November 29, 2021. You say that having to 
pay this copayment will be a hardship on you. The Plan denied your request. The Plan says you are responsible 
to pay a $45 copayment for treatment by a specialist. 
 
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 $45 
copayment for surgery services in a specialists office.  
 
You have been asked to pay a $45 copayment for an injection. An injection 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 $45 copayment for an injection on November 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve electroacoustic evaluation for hearing aid; binaural 
(92595) and repair/modification of a hearing aid (V5014). 
 
You asked the Plan to pre-approve electroacoustic evaluation for hearing aid and repair of hearing aids. You 
say that the hearing aid evaluation and repair is necessary. The Plan denied your request. The Plan says these 
services are not covered when provided out-of-network. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related 
services.  
 
Though electroacoustic evaluation for hearing aid and repair of hearing aids may be appropriate in this case, 
neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that 
the Plan does not have to pre-approve electroacoustic evaluation for hearing aid; binaural (92595) and 
repair/modification of a hearing aid (V5014).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc. 
 
You asked the Plan to pre-approve Monovisc. You say that the physician's office does not use Synvisc-one, and 
uses Monovisc. The Plan denied your request. The Plan says this request is not medically necessary because the 
enrollee has not failed the preferred viscosupplements for their arthritis. 
 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 Monovisc. Our reviewer says that 
Monovisc is not reasonable or necessary. Our physician reviewer found there is no indication that the patient 
has tried and failed the required drug(s). Our reviewer also found that there is no indication that the Plan's 
required drug(s) 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 Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital services provided to the enrollee on October 18, 
2021, and October 19, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider was not eligible. 
 
Medicare rules say that services must be provided by providers who are enrolled in the Medicare program.  
 
This provider is not eligible to bill Medicare. The Plan did not pre-approve the services. We found no 
exception that would require the Plan to pay for these items/services. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does 
not have to pay for hospital services provided to the enrollee on October 18, 2021, and October 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Taltz auto-injector. 
 
You asked the Plan to pre-approve self-administered drug. You say that this is medically necessary. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not 
covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug 
benefits. 
 
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 Taltz auto-injector.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing services provided on March 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation 
does not contain an order. 
 
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the 
medical record, his or her intent that the test be performed.  
 
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab 
requisition stating exactly which testing was to be performed. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met.  
 
 
 
 
 
 Therefore, we decided that the Plan does not have to pay for the drug testing services provided on March 15, 
2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for skilled nursing facility (SNF) care 
provided by an out-of-network (OON) provider from February 26, 2022, to March 2, 2022. 
 
You asked the Plan to waive the coinsurance for the OON SNF care. You say that you had complications 
following surgery. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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% 
coinsurance for each SNF stay at an out-of-network (OON) facility.  
 
The file shows that the Plan verified the provider is out-of-network. Therefore, you have been asked to pay 
$6,692.68, which is 50% of the allowed amount for the OON SNF care ($13,385.36 allowed amount x 50% 
coinsurance = $6,692.68). The OON SNF care falls within the Skilled Nursing Facility (SNF) Care 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 coinsurance for skilled nursing facility (SNF) care provided by 
an out-of-network (OON) provider from February 26, 2022, to March 2, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crutch substitute, lower leg platform, with or without 
wheels (E0118). 
 
 
You asked the Plan to pre-approve a crutch substitute. You say that you broke your ankle in 3 places and is 
having surgery on June 14, 2022. You have been on crutches but cannot walk on them as your right leg is weak 
and you have fallen 5 times. You need this scooter so you can get around. The Plan denied your request. The 
Plan says this is not a covered item as there is insufficient published literature demonstrating safety and 
effectiveness to establish medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-
approve a crutch substitute, lower leg platform, with or without wheels (E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone graft (D6104), and second stage implant surgery 
(D6011) provided by a participating provider. 
 
You asked the Plan to pre-approve a bone graft and second stage implant surgery. You say that these services 
are medically necessary. The Plan denied your request. The Plan says the requested 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 requested items or services are not 
among those covered under this benefit.  
 
 
 
 
 
  
Therefore, we decided that the Plan does not have to pre-approve a bone graft (D6104), and second stage 
implant surgery (D6011) provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you are appealing because it is medically 
necessary for the enrollee to receive LTACH services. The Plan denied your request. The Plan says the enrollee 
can receive this care in another setting, such as in their current acute care facility, an Inpatient Rehabilitation 
Facility (IRF), a Custodial Long Term Care Facility or at home with home health services or an outpatient 
setting. 
 
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 the review indicates that the 90-year-old enrollee with a history of respiratory failure 
on a ventilator, Covid-19, CAD, atrial fibrillation, high cholesterol, dementia, kidney cancer, blood cancer, 
kidney disease, acid reflux and hypothyroidism who was admitted to the hospital from the LTACH due to low 
blood pressure and dropping blood counts. The enrollee was treated with blood transfusions. The enrollee was 
found to have a UTI which required IV antibiotics. The enrollee was evaluated and has been recommended for 
hospice care. 
 
There is no documentation provided indicating medical necessity for admission to a 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 he/she 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 service is 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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (80050, 82306, 85652) provided on November 
24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-
covered code. The rules explicitly say that screening tests, with the exception of the few tests listed in the 
Medicare rules section, are not covered. 
 
You have requested payment for services billed under code 80050. Medicare does not cover or pay for services 
billed under this code. 
 
The testing (82306, 85652) at issue in this appeal was requested solely for screening purposes. Medicare does 
not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the services (80050, 82306, 85652) provided on November 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide an additional 60-70 routine transportation trips for the 2022 
calendar year. 
 
You asked the Plan to provide additional transportation. You say that you do not have personal transportation 
and the cost of private transportation is excessive. You need these trips covered so that you may get to your 
medical appointments. The Plan denied your request. The Plan says your benefit covers a maximum of 24 
routine transportation trips per year. Additional trips are not a covered benefit. 
 
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 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to provide an additional 60-70 routine transportation trips for the 2022 
calendar year.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional routine transportation trips. 
 
You asked the Plan to provide additional transportation. You say that you need additional transportation. The 
Plan denied your request. The Plan says your benefit covers 20 transportation trips per year. Additional trips 
are not a covered benefit. 
 
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 20 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 provide additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neulasta (J2506). 
 
You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says the use of this drug is 
not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Neulasta. Our reviewer says that the 
elements of the coverage criteria are not satisfied, and Neulasta cannot be recommended. Our physician 
reviewer found the enrollee has a diagnosis of stage 1 adenocarcinoma of the lung and is planned to receive 
chemotherapy that does not have a clinically significant risk of febrile neutropenia.  The Food and Drug 
Administration has not stated that Neulasta is indicated for the enrollee's condition. Our reviewer found that the 
Medicare approved cancer drug compendia do not contain a supportive citation for the use of Neulasta in the 
enrollee's clinical situation. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Neulasta (J2506).