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

 
We decided that the Plan does not have to issue reimbursement for the gym membership provided from  
January 1, 2023, through May 31, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are 
not a covered benefit.  
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
The Plans rules for coverage of gym benefits have not been met because the membership purchased in this 
case is not a covered benefit.  
 
  
 
 
 
Specifically, the Plans contract states that coverage is provided for a fitness membership through the Plans 
select fitness provider. However, in this case, you purchased a gym membership from an out-of-network 
provider. Additionally, the Plans contract states that enrollees receive $300 every three months on a Flex card 
that may be utilized for qualifying fitness expenses that includes fitness centers, gyms, and athletic clubs. 
Therefore, we decided that the Plan does not have to issue reimbursement for the gym membership provided 
from January 1, 2023, through May 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and the core buildup, 
including any pins when required (D2950) provided on May 3, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under the supplemental 
dental policy.  
 
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 dental items provided are not 
among those covered under this benefit.   
 
 
 
Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and the core 
buildup, including any pins when required (D2950) provided on May 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Volara system for oscillation and lung expansion. 
 
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your 
request. The Plan says medical studies have not proven that this item is helpful. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 system. Our reviewer says that the 
requested system is not medically reasonable or necessary. Our physician reviewer found that the enrollee has 
severe chronic obstructive pulmonary disease. The records do not support a diagnosis of bronchiectasis, and 
there is no diagnosis of cystic fibrosis or neuromuscular disease. The Volara device has 3 components: Airway 
oscillation, positive end expiratory pressure, and nebulization. The device has not been studied enough to show 
benefit in the treatment of any chronic lung disease. There is inadequate evidence that this device is as, or 
more, effective than other devices in achieving airways clearance.  Medicare does not cover its use in the 
outpatient 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 the system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Volara system for oscillation and lung expansion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve test strips. 
 
You asked the Plan to pre-approve test strips. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says only the preferred brand products listed in the EOC 
are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits.  
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for test strips. Therefore, we decided that the Plan does not have to pre-approve test strips.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total disc arthroplasty. 
 
You asked the Plan to pre-approve a total disc arthroplasty. You say that the enrollee is having severe pain, 
numbness, and weakness in the arm and hand. The Plan denied your request. The Plan says the requested 
service is not covered. 
 
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 a total disc arthroplasty. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee has had a previous fusion. A total disc arthroplasty in the spine is 
considered experimental and not approved when combined with a fusion. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a total disc arthroplasty have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a total disc arthroplasty.
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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 documentation does not support necessity for admission to an IRF. The complexity 
of the enrollee's medical, rehabilitation, and nursing needs (combined complexity) does not require an acute 
hospital inpatient rehabilitation stay with an interdisciplinary approach to rehabilitative care. The enrollee's 
rehabilitation needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing 
facility. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the home ventilator (E0466). 
 
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan 
denied your request. The Plan says the ventilator is not necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our physician 
reviewer found there is no diagnosis of thoracic restrictive disease or neuromuscular disease. This enrollee does not have a diagnosis for which Medicare covers a home ventilator. Medicare does not cover a home ventilator 
when used at settings that can be provided with bilevel positive airway pressure (BiPAP). 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve the home ventilator (E0466).
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Sandostatin LAR Depot. 
 
You asked the Plan to pre-approve Sandostatin LAR Depot. The Plan denied your request. The Plan says that 
the LAR Depot form of the drug would not be appropriate for daily intravenous use. 
 
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 Sandostatin LAR Depot. Our reviewer 
says that the use of the requested drug is supported by one of the major drug compendia. Our physician 
reviewer found that the documentation also supports that the requested drug is safe and effective and otherwise 
reasonable and necessary for this 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 Sandostatin LAR Depot have been met. Therefore, we decided that the Plan has 
to pre-approve Sandostatin LAR Depot.  
 
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: 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 due to your condition, you need to be continuously 
monitored. The Plan denied your request. The Plan says a SNF admission is not medically necessary.   
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that you do not have daily skilled nursing needs that require the specialized skill, 
knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that 
require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require 
daily skilled nursing or skilled therapy on an inpatient basis in a SNF 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the facet joint injections provided on November 17, 2022. 
 
You asked the Plan to pay for the injections. You say that you would like the additional documentation to be 
reviewed and to allow payment for the medically necessary procedure. The Plan denied your request. The Plan 
says that the facet joint injections are not medically necessary.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 pay for the injections. Our reviewer says that the 
enrollee did meet the LCD coverage criteria. Our physician reviewer found that the enrollee has clear 
documentation supporting the performance of diagnostic medial branch blocks. Therefore, the procedures were 
medically reasonable and 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 injections have been met. Therefore, we decided that the Plan has to pay for 
the facet joint injections provided on November 17, 2022.  
 
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 Darzalex Faspro (J9144), Diphenhydramine HCL (J1200), and 
Famotidine (J3490). 
 
You asked the Plan to pre-approve Darzalex Faspro, Diphenhydramine HCL, and Famotidine. You say that the 
services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, 
coverage criteria has not been met. 
 
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 Darzalex Faspro, Diphenhydramine 
HCL, and Famotidine. Our reviewer says that the services are medically necessary. Our physician reviewer 
found the use is supported by one of the major drug compendia or by clinical research that appears in a CMS-
approved medical journal. The daratumumab+Velcade+Revlimid is an approved recommended regimen for 
multiple myeloma in NCCN. In this case, the Revlimid is being switched to Pomalidomide due to intolerance. 
Studies have shown Pomalidomide is a good second line therapy drug in lieu of Revlimid so there is evidence 
that the Darzalex Faspro+Velcade+pomalidomide combination appears effective with Revlimid being switched 
out to Pomalidomide. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Darzalex Faspro, Diphenhydramine HCL, and Famotidine have been met. 
Therefore, we decided that the Plan has to pre-approve Darzalex Faspro (J9144), Diphenhydramine HCL 
(J1200), and Famotidine (J3490).  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mouth guard (D9944). 
 
You asked the Plan to pre-approve a mouth guard. You say that this item is medically necessary. The Plan 
denied your request. The Plan says the requested item is not a covered 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. 
 
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 
mouth guard (D9944).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the maxillary partial denture  resin base (D5211), and mandibular 
partial denture  resin base (D5212). 
 
You asked the Plan to pre-approve the maxillary and mandibular partial dentures. You say that you broke your 
tooth that held your denture and you needed to have it extracted. You also say that due to the extraction, your 
top dentures fall constantly, and as a result, you are unable to eat. The Plan denied your request. The Plan says 
that one partial dentures every three years. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided proof that they paid for the previous 
dentures to support that your benefit for these services have been exhausted. The Plan has not substantiated 
their denial reason. Therefore, we decided that the Plan has to pre-approve a maxillary partial denture  resin 
base (D5211), and mandibular partial denture  resin base (D5212).  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a computed tomography (CT) scan of the maxillofacial area provided 
on March 29, 2023. 
 
You asked the Plan to pay for the CT scan. You say that the provider failed to request prior authorization. The 
Plan denied your request. The Plan says that the criteria for coverage have not been met. 
 
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 pay for the CT scan. Our reviewer says that the 
service was medically necessary. Our physician reviewer found you had longstanding nasal obstruction and has 
used nasal steroid spray for longer than 6 weeks as well as Afrin daily. Your physical exam of the nasal cavity 
was abnormal. Based upon your history including the use of nasal steroids and your abnormal physical exam 
the CT of the sinuses done March 29, 2023, was medically appropriate. 
 
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 pay for a 
computed tomography (CT) scan of the maxillofacial area provided on March 29, 2023.  
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided on April 27, 2022.  
 
You asked the Plan to pay for the physical therapy services. You say that the records provided support that the 
services provided were medically necessary.  The Plan denied your request. The Plan says they do not cover 
charges for treatment of TMJ other than by an open cutting operation.  
 
The Plan must follow Medicare rules. The rules say that Medicare covers treatment for TMJ syndrome only 
when the condition or symptom is medical in nature. The treatment must also be medically 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 the physical therapy services. Our reviewer 
says that the criteria for coverage have not been met. Our physician reviewer found the documentation 
available for review did not include a description of previous treatment such as patient education, the use of 
medications or bite splints.  There was not a relevant medical history or pertinent tests/procedures from the 
referring medical provider. There is no indication the member failed initial conservative treatment that would 
require referral for skilled outpatient rehabilitation.  The requested therapy services were not an appropriate 
duration and frequency for treatment of the enrollees medical condition and therefore were 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 physical therapy services have not been met. Therefore, we decided that the 
Plan does not have to pay for physical therapy services provided on April 27, 2022.