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

 
We decided that the Plan does not have to pre-approve dental crowns-porcelain fused to high noble metal for 
teeth number 22 and 27 (D2750 x 2). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested dental items 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 these items 
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 these items. Our reviewer says that you 
do not meet criteria for coverage of the requested dental items. Our physician reviewer found that a request for 
dental crowns for teeth number 22 and 27 has been made. Tooth number 22 has an existing distal restoration 
that may include the facial and/or mesial surfaces. The amount of damaged tooth structure is less than 30 
percent. Tooth number 27 has a deep distal carious lesion that appears to involve the facial and lingual surfaces 
and a small incisal lesion, with a total amount of damaged tooth structure of about 40 percent. A standard 
composite restoration would be reasonable to place in this situation on either tooth number 22 and 27. The Plan 
provides criteria for crowns as follows, " In general, criteria for crowns will be met only for permanent teeth 
needing multi-surface restorations where other restorative materials have a poor prognosis. Permanent anterior 
teeth must have pathologic destruction to the tooth by caries or trauma and must involve four or more surfaces 
and at least 50% of the incisal edge." Given the restorability of either tooth with composite resin, it appears that 
crowns are not medically necessary for either tooth number 22 or 27.  
 
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 these items have not been met. Therefore, we decided that the Plan does not 
have to pre-approve dental crowns-porcelain fused to high noble metal for teeth number 22 and 27  
(D2750 x 2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve the services. You say that this 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 pre-approve the services. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found that Injectafer is 
indicated for the treatment of iron deficiency anemia. The provided records in this case document iron 
deficiency with an iron saturation of 11.9% as of 05/22/2023 but no recent records have been provided 
documenting a low hemoglobin of hematocrit level to confirm the diagnosis of anemia. 
 
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. Therefore, we decided that the Plan does not 
have to pre-approve Injectafer.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the chest. 
 
You asked the Plan to pre-approve the CT scan. You say that the requested CT scan is medically necessary. 
The Plan denied your request. The Plan says that a previous test was done and there is no reason for another 
test; therefore, the requested CT scan is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically 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 the CT scan. Our reviewer says that the 
CT scan of the chest is medically necessary. Our physician reviewer found that a chest x-ray of July 11, 2022, 
was compared to June 11, 2021, and revealed a new 5 mm nodule on the right. The notes indicate a nodule was 
seen on CT, but this seems to be a misprint.  The nodule was noted on a radiology report concerning a plain 
chest x-ray of July 11, 2022. Based upon a new appearing 5 mm nodule on chest x-ray a CT of the chest for 
follow-up is indicated. 
 
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 CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a CT scan of the chest.  
 
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 waive the copayment for the inpatient hospital stay provided on 
December 15, 2022, to December 18, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were told this 
would be fully covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
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 $350 
copayment for inpatient hospital care. 
 
You have been asked to pay a $350 copayment for the inpatient hospital stay. This item/service falls 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 the inpatient 
hospital stay provided on December 15, 2022, to December 18, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable paraffin bath unit (E0235). 
 
You asked the Plan to pre-approve a portable paraffin bath. You say that you have a lot of pain in your hands 
and wrists as well as swelling. You say that you take Flexural and arthritis medication. You say that you have 
not done any physical therapy. You also say that you had an injection but do not remember the name of the 
medication. The Plan denied your request. The Plan says there was no evidence provided to show that you have 
completed a trial period of a portal paraffin bath and therefore it cannot be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that a portable paraffin bath may be covered when the 
patient has undergone a successful trial period of paraffin therapy ordered by a physician and the patients 
condition is expected to be relieved by long term use of this modality. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable paraffin bath have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a portable paraffin bath unit (E0235).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 sensor/reader. 
 
You asked the Plan to pre-approve a FreeStyle Libre 2 sensor/reader. You say that the enrollee is unable to 
continue testing their blood sugar using the standard blood glucose monitor, and would like a CGM to be 
covered. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage. 
 
 
 
 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. Based on this information, we decided that Medicare rules for coverage of a 
FreeStyle Libre 2 sensor/reader have not been met. Therefore, we decided that the Plan does not have to pre-
approve a FreeStyle Libre 2 sensor/reader.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
November 30, 2022.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service November 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 for date of service October 12, 2022. 
 
You asked the Plan to pay for procedure code 71045. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and was correctly 
denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on November 1, 2022. Comparison of the two claims shows these are exact duplicates. 
There is no evidence presented to support that the billed items/services were provided twice on the same date.  
 Based on this information, we decided that the Medicare rules for procedure code 71045 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 71045 for date of service October 
12, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a physician visit provided on November 3, 2022. 
 
You asked the Plan to pay for physician visit. You say that hospice coverage was revoked. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for a physician visit provided on November 3, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
February 1, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service February 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 6, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 6, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Lupron Depot. 
 
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 metastatic prostate 
cancer. He has not tried and failed the Plan's required drug, Eligard. The records do not show that the required 
drug would be contraindicated or less effective; therefore, Lupron Depot 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 Lupron Depot.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 92555 billed for date of service November 3, 
2022.  
 
You asked the Plan to pay for procedure code 92555. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 92555 is bundled into payment for code 92556. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 92555 is a column II code to column I code 92556 with a modifier indicator of 0. The column II code is therefore not 
payable. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 92555 billed for date of service November 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Leqvio. 
 You asked the Plan to pre-approve Leqvio. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet 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 Leqvio. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has diagnoses of diabetes, hyperlipidemia and peripheral vascular disease.  The 
documentation does not support that the enrollee has tried and failed Praluent. The documentation does not 
support that Praluent would likely be less effective and/or likely have adverse effects for the enrollee. 
Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Leqvio have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Leqvio.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided from December 6, 2022, to 
December 22, 2022. 
 
You asked the Plan to pay for psychotherapy. You say that you were advised the claim should have paid under 
your out-of-network benefits. The Plan denied your request. The Plan says this type of provider is not part of 
the Medicare program. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist. 
Medicare says that a Marriage Family Therapist is not eligible to participate in the Medicare program.  
Therefore, we decided that the Plan does not have to pay for psychotherapy provided from December 6, 2022, 
to December 22, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve services with an in-network oncologist at an out-of-network 
tertiary facility. 
 
You asked the Plan to pre-approve services with an in-network oncologist at an out-of-network tertiary facility. 
You say that the request for services at a tertiary facility is medically necessary. The Plan denied your request. 
The Plan says that the enrollee can stay in-network.  
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet the enrollees needs. The enrollees contract with the Plan says that, with few 
exceptions, enrollees must use contract providers for care.  
 
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 for services with an in-network oncologist who 
practices at an out-of-network tertiary facility. Our reviewer says that the requested services at a tertiary facility 
are medically necessary. Our physician reviewer found the plan's denial is not medically justified on the basis 
that it is offering adequate care to meet the enrollee's medical needs through referral to the in-network 
providers. The requesting provider prefers to see the enrollee at Memorial Sloan Kettering in order to offer 
state of the art care including access to clinical trials. The plan has not demonstrated that this is available within 
network.  
 In this case, the records show that the enrollee's condition is unique in that it would make it medically 
necessary for him to see the requested provider. The enrollee has progressed through standard treatment and 
needs to explore the option of clinical trial.  
 
The Plan has not shown that they have in-network providers who meet the Standards of Care required for 
treatment of the enrollee's condition. The National Comprehensive Cancer Network (NCCN) Guidelines for 
pancreatic cancer recommend referral to a clinical trial when available. There is no standard of care for 3rd line 
pancreatic cancer.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of services with an in-network oncologist at an out-of-network tertiary facility 
have been met. Therefore, we decided that the Plan has to pre-approve services with an in-network oncologist 
at an out-of-network tertiary facility.  
 
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: Favorable

 
We decided that the Plan has to pre-approve Keytruda (pembrolizumab). 
 
You asked the Plan to pre-approve the medication. You say that you need to begin treatment for prostate 
cancer. The Plan denied your request. The Plan says that this drug is not supported for the treatment of prostate 
cancer. 
 
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 the medication. Our reviewer says that 
the requested drug is considered medically reasonable and necessary. Our physician reviewer found NCCN 
compendia supports the use of the drug in certain circumstances as a single-agent for castration-resistant distant 
metastatic (M1) disease that is microsatellite instability-high (MSI-H), mismatch repair deficient (dMMR), or 
tumor mutational burden (TMB) =10 mutations/megabase, and if received prior docetaxel and prior novel 
hormone therapy. 
 
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 medication have been met. Therefore, we decided that the Plan has to pre-
approve Keytruda (pembrolizumab).  
 
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.