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

 
We decided that the Plan does not have to pay for dental services provided on January 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits.  
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided on January 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care and an outpatient 
diagnostic test provided on December 16, 2022, to December 24, 2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care and an outpatient diagnostic test. You 
say that you disagree with the copayment. 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 $150 
copayment per day for days 1-7 for inpatient hospital care and a $20 copayment for outpatient hospital 
services/diagnostic procedures and tests.  You have been asked to pay a $150 copayment per day for days 1-7 for inpatient hospital care and a $20 
copayment for an outpatient diagnostic test. The total amount for the inpatient care is $450 ($150 x 3 days = 
$450). The total amount for all services rendered is $470 ($450 + $20 = $470). This item/service falls within 
the inpatient hospital care and outpatient hospital services/diagnostic procedures and tests 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 inpatient hospital care and an outpatient diagnostic test 
provided on December 16, 2022, to December 24, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve durvalumab (Imfinzi) (J9173). 
 
You asked the Plan to pre-approve durvalumab. You say that the enrollee has a separate new primary lung 
cancer. You also say that the enrollee's past diagnosis should not be part of this decision. The Plan denied your 
request. The Plan says the requested use of the drug is not supported in the adjuvant setting. 
 
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 durvalumab. Our reviewer says that the 
requested drug, durvalumab, is not medically necessary. Our physician reviewer found the provided records 
indicate that the enrollee developed a new primary lung cancer while on immunotherapy. The reviewer found that the requested use of durvalumab is not Food and Drug Administration (FDA) approved for the enrollees 
diagnosis. The reviewer found that the requested use is not supported by one of the major drug compendia or 
by clinical research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved 
journals) either. Therefore, the reviewer found that the requested use of durvalumab is not medically reasonable 
or 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 durvalumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve durvalumab (Imfinzi) (J9173).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trivisc. 
 You asked the Plan to pre-approve Trivisc. You say that the doctor prefers this medication. You also say that it 
is available to buy and bill in office. The Plan denied your request. The Plan says the enrollee has not tried and 
failed the preferred drugs, Monovisc, Orthovisc, Synvisc or Synvisc One. 
 
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 Trivisc. Our reviewer says that the step 
therapy criteria have not been met. Our physician reviewer found the provided documentation does not show 
that the enrollee has tried and failed the preferred drugs. The reviewer also found that there is no 
documentation provided indicating that the Plans required drugs would likely be less effective and/or likely 
have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been 
met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Trivisc have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Trivisc.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection. 
 
You asked the Plan to pre-approve the injection. You say that you need a series of three shots. You say that you 
already had one and need the second one. The Plan denied your request. The Plan says an epidural steroid 
injection is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that an 
epidural steroid injection is not medically necessary. Our physician reviewer found that you have had 3 
epidural steroid injections with the last one on October 5, 2023, producing 70% pain relief. However, it has not 
been three months since the last injection. Therefore, the request is not 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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the genicular nerve block. 
 
You asked the Plan to pre-approve the genicular nerve block. You say that you need the shot now due to the 
pain in your knees. You say that although you did have a cortisone shot done, you still need the injection to 
further assist with the pain in your knees. The Plan denied your request. The Plan says the genicular nerve 
block is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the genicular nerve block. Our reviewer 
says that the genicular nerve block is not medically necessary. Our physician reviewer found that the genicular 
nerve block is the subject of ongoing clinical trials and is considered experimental and investigational. 
 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 genicular nerve block have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the genicular nerve block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a heavy-duty power wheelchair (PWC) (K0862) and 
accessories. 
 
You asked the Plan to pre-approve a heavy duty PWC. You say that the item is medically necessary. The Plan 
denied your request. The Plan says you do not meet the weight requirements for this wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that a heavy duty PWC coded K0862 has a patient 
weight capacity of 301 to 450 pounds.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a heavy duty PWC have not been met. Therefore, we decided that the Plan does not have to pre-
approve a heavy-duty power wheelchair (PWC) (K0862) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power 
options (tilt/recline, legrests, seat elevator) and accessories. 
 
You asked the Plan to pre-approve a Group 3 power wheelchair with multiple power options. You say that this 
is medically necessary for the enrollee. The Plan denied your request. The Plan says the notes do not show that 
the enrollee has a medical need for the requested power options. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with multiple power 
options may be covered when certain criteria are met. 
 
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 Group 3 power wheelchair with 
multiple power options. Our reviewer says that the requested Group 3 power wheelchair with multiple power 
options is not medically necessary. Our physician reviewer found the provided documentation does not show 
that the enrollee has high risk for skin breakdown, uses a catheter intermittently, has spasticity or requires an 
alternative means of managing power drive. Therefore, the reviewer found that the requested Group 3 power 
wheelchair with multiple power options is not medically reasonable or 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 a Group 3 power wheelchair with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple 
power options (tilt/recline, legrests, seat elevator) and accessories.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete denture - maxillary (D5110) provided on July 20, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 May 3, 2021. Therefore, 
we decided that the Plan does not have to pay for complete denture - maxillary (D5110) provided on July 20, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs from July 26, 2023, through July 
28, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
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 pay for the self-administered drugs from 
July 26, 2023, through July 28, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee needs LTACH services. The 
Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not 
require transfer to an LTACH. 
 
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 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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital. 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. Given there are offered alternatives, LTACH admission is 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 LTACH services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs from September 1, 2023, through 
September 3, 2023. 
 
You asked the Plan to pay for the medication. The Plan denied your request. The Plan says the medication is 
not covered as a medical benefit under the Plan. 
 
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 pay for the self-administered drugs from 
September 1, 2023, through September 3, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: 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 cannot receive services at a 
lower level of care and will need acute care for another 3-4 weeks. The Plan denied your request. The Plan says 
the enrollee is not currently safe for transfer, and when they are ready to leave the hospital, they can safely 
receive this care in another setting, such as a skilled nursing facility (SNF). 
 
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 recent notes describe the enrollee as now extubated tolerating room air, tolerating 
wound care with vacuum-assisted closer (VAC) and drain management, and requiring ongoing therapy. The enrollee appears to be improving with current treatment and should only require short-term additional acute 
care services that can safely be provided at the current facility until more stable and appropriate for transfer to a 
lower level of care soon. The enrollee does not require services at the LTACH that are not already available at 
the current facility. 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 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 lab services provided on May 17, 2023. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment-includes placement (D6057) and 
abutment supported porcelain/ceramic crown (D6058) provided on December 12, 2022. 
 
You asked the Plan to pay for custom fabricated abutment-includes placement and abutment supported 
porcelain/ceramic crown. You say that this should be covered. The Plan denied your request. The Plan says this 
is not a covered service. 
 
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 pay for custom 
fabricated abutment-includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on December 12, 2022.
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 given the enrollee's high vascular risk, notably toe 
pressure of zero, they require ongoing monitoring by physicians as appropriate at an acute inpatient rehab 
hospital. The Plan denied your request. The Plan says the inpatient rehabilitation facility (IRF) services you are 
requesting do not meet the requirements for approval.  
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar spine surgery. Medical problems are stable. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
no documented need for intensive rehabilitation services. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF.  
 
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 a group 1 power operated vehicle (K0800). 
 
You asked the Plan to pre-approve a group 1 power operated vehicle . You say that the item is medically 
necessary. The Plan denied your request. The Plan says your condition can be improved by a walker, cane or 
manual wheelchair. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a group 1 power operated vehicle (K0800).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the sales tax (S9999) for the power scooter purchased on 
June 9, 2023. 
 
You asked the Plan to pay for the sales tax. You say that the service should be covered. The Plan denied your 
request. The Plan says Medicare does not reimburse separately for sales tax. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales 
tax. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the 
sales tax (S9999) for the power scooter purchased on June 9, 2023.