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

 
We decided that the Plan does not have to pre-approve carboplatin, Abraxane and Jemperli. 
 
You asked the Plan to pre-approve these drugs. You say that the enrollee is having nerve pain and wants to 
switch from a drug called taxol to abraxane. The Plan denied your request. The Plan says having nerve pain is 
not a reason to switch drugs. 
 
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 these drugs. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found clinical experience with the nanoparticle 
albumin-bound nanoparticle formulation of paclitaxel (nabpaclitaxel, Abraxane) suggests that while the overall toxicity profile is better as compared with conventional paclitaxel, the incidence of transient sensory 
neurotoxicity may be slightly higher. 
 
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 drugs have not been met. Therefore, we decided that the Plan does not 
have to pre-approve carboplatin, Abraxane and Jemperli.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 receiver. 
 
You asked the Plan to pre-approve the Dexcom G7 receiver. You say that the enrollee states that fingersticks 
are quite painful and does not check blood sugars regularly or consistently.  The Plan denied your request. The 
Plan says the enrollee does not meet criteria for the Dexcom G7 receiver. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the Dexcom G7 receiver. Our reviewer 
says that this item is not medically necessary. Our physician reviewer found coverage criteria for CGM require 
low blood glucose sugar or insulin use. The enrollee, despite not checking blood glucose sugar much has 
brought her A1C from 8 down to 6.8 and the Mounjaro is being increased. Hence, although the CGM may help, 
coverage criteria are not met as there are no low blood glucose sugar noted and is not on insulin. 
 
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 Dexcom G7 receiver have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Dexcom G7 receiver.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and the periodic oral evaluation 
(D0120) provided on October 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered because you are 
diabetic and needs three to four cleanings per year. The Plan denied your request. The Plan says your benefit 
for the requested services have already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 28, 2023, and 
June 13, 2023. Therefore, we decided that the Plan does not have to pay for the dental cleaning (D1110) and 
the periodic oral evaluation (D0120) provided on October 31, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on June 7, 
2023. 
 
You asked the Plan to pay for the ED services. The Plan denied your request. The Plan says Medicare payment 
cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 
 
 We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on June 7, 2023.
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 due to the enrollee medical condition this 
is medically necessary. The Plan denied your request. The Plan says this does not meet the criteria for 
admission. 
 
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 transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended. 
 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 panel testing billed for date of service August 9, 2023. 
 
You asked the Plan to pay for the billed testing. You say that all services were properly ordered. The Plan 
denied your request. The Plan says one code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that for tests for infectious agents, a single laboratory 
procedure shall be reported as one unit of service whether it generates one or multiple results. Multiple codes 
should only be used when multiple procedures, multiple methodologies, or multiple test kits are medically 
necessary and used to perform the test.  
 
 The file shows that the panel testing was billed using multiple codes including 87641, 87653, 87640, 87481, 
and 87798. We looked at the file and Medicare rules. The documentation supports that this panel used the 
nucleic acid probe technique. There is no evidence that multiple procedures, multiple methodologies, or 
multiple kits were used in this case. As such, a single code with one unit of service should be used. Based on 
this information, we decided that Medicare rules for coverage of the testing panel have not been met. 
Therefore, we decided that the Plan does not have to pay for the panel testing billed for date of service August 
9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for the outpatient hospital services provided 
from September 12, 2023, to October 6, 2023. 
 
You asked the Plan to waive the cost sharing for the outpatient hospital services. You say that you feel you 
should not have to pay these bills. 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 $200 
copayment for outpatient hospital services.  
 
You have been asked to pay a $198.11 copayment per day for the outpatient hospital services. These services fall within the outpatient hospital services benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing 
for the outpatient hospital services provided from September 12, 2023, to October 6, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you were only approved for 3 more days you need 
additional time in the skilled nursing facility. The Plan denied your request. The Plan says your request does 
not meet Medicare guidelines because you no longer require skilled services on a daily inpatient basis and the 
continuation of SNF 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 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 and/or skilled therapy on an inpatient basis in a skilled nursing facility (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 skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring device (A9279), provided on August 16, 
2023. 
 
You asked the Plan to pay for the monitoring device . You say that the item was medically necessary. The Plan 
denied your request. The Plan says this is a non-covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that A9279 are statutorily non-covered.   
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the monitoring device have not been met. Therefore, we decided that the Plan does not have to pay 
for the monitoring device (A9279), provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extractions (D7210) and alveoloplasty (D7310) 
provided on June 29, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered. The Plan 
denied your request. The Plan says the cost share was assessed correctly. 
 
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. 
 
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay 
more for the extractions (D7210) and alveoloplasty (D7310) provided on June 29, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Orencia. 
 You asked the Plan to pre-approve Orencia. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the Plan requires a trial of Remicade, Infliximab, Inflectra, or Simponi Aria 
before it will approve Orencia. 
 
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 Orencia. Our reviewer says that the 
enrollee does not meet criteria for a step therapy exception for Orencia. Our physician reviewer found the 
enrollee has not tried and failed the Plan's preferred drugs of Remicade, Infliximab, Inflectra, or Simponi Aria. 
The record does not show that these drugs would likely be less effective and/or have adverse effects 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 Orencia have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Orencia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 10, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted proof of 
delivery along with other supporting documentation, but the claim keeps denying for missing this information. 
The Plan denied your request. The Plan says the provider is not enrolled in Medicare as a durable medical 
equipment supplier. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
 Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous 
glucose monitor (CGM) provided on August 10, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81456 billed for date of service June 19, 
2023. 
 You asked the Plan to pay for procedure code 81456. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 81456 is bundled into payment for code 81455. 
 
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 81456 
is a column II code to column I code 81455. This claim has not been billed with an appropriate modifier to 
bypass the edit. 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 81456 billed for date of service June 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) on tooth #9. 
 
You asked the Plan to pre-approve the dental services. You say that this service is necessary. The Plan denied 
your request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service April 19, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) on tooth #9.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0110). 
 
You asked the Plan to pre-approve additional transportation trips. You say that the enrollee has no 
transportation and needs unlimited rides per year for her appointments. The Plan denied your request. The Plan 
says additional trips would exceed the enrollee's benefit limit. 
 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 50 trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that the enrollee has 
used twenty-nine (29) one-way transportation trips out of the allowed fifty (50) one-way trips approved. Once 
50 trips are used, the benefit will be exhausted. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve additional routine transportation trips (A0110).
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 the enrollee meets the criteria for 
medical complexity requiring physician oversight as well as skilled nursing care and therapy. The Plan denied 
your request. The Plan says admission to an LTACH is not medically necessary.  
 
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 that the enrollee appears to be somewhat unstable and requires additional acute care 
services that can safely be provided at the current facility until more stable and appropriate for transfer. There 
are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as the enrollee is not yet stable for transfer and as it 
would not be clinically advantageous at this time.  
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laboratory services, the office visit, and the 
ultrasounds to be provided by an OON provider.  
 
You asked the Plan to pre-approve the laboratory services, the office visit, and the ultrasounds. You say that 
you are requesting reconsideration of the denied services. The Plan denied your request. The Plan says the 
services were not approved. 
 
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 Plan has network providers available who are capable of providing the items/services at issue in this 
appeal. (Please note, items and services received in-network are still subject to any other Medicare coverage 
rules that apply.) 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 laboratory services, the office visit, and 
the ultrasounds to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies. 
 
You asked the Plan to pay for the CGM supplies. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the provider is not enrolled with Medicare as DME provider and the item 
were obtained through an unsolicited telephone call.  
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) 
supplies.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve resin-based composites 4 or more surfaces- anterior 
(D2335 x5), resin-based composites 3 surfaces-posterior (D2393 x2), resin-based composites 4 surfaces-
posterior (D2394) and application of desensitizing medicament (D9910 x2). 
 
You asked the Plan to pre-approve these dental services. You say that this was not due to attrition, abrasion, 
erosion. The Plan denied your request. The Plan says the plan does not provide benefits to restore damage due 
to attrition, abrasion, erosion. The x-rays show the tooth damage was caused by this. 
 
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 dental 
services 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 dental services. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found included were x-rays that are 
unreadable due to the poor contrast of the images. Diagnoses cannot be made with undiagnostic x-rays. 
 
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 dental services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve resin-based composites 4 or more surfaces- anterior (D2335 x5), resin-based 
composites 3 surfaces-posterior (D2393 x2), resin-based composites 4 surfaces-posterior (D2394) and 
application of desensitizing medicament (D9910 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns on teeth 23,24,25,26 (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. The Plan denied 
your request. The Plan says your $1,500 annual maximum has already been exhausted. 
 
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, certain limitations apply. The record 
shows your $1,500 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pre-
approve crowns on teeth 23,24,25,26 (D2740).