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

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5050) purchased from 
the out-of-network (OON) provider on May 16, 2023.  
 
You asked the Plan to issue reimbursement 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 the items were purchased from an 
out-of-network provider, without prior authorization.  
 
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 issue reimbursement for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the items at issue in this appeal. The Plan did not pre-approve the items at issue.   
 
 
 
We found no exception that would require the Plan to issue reimbursement for these items. Therefore, we 
decided that the Plan does not have to issue reimbursement for the hearing aids (V5050) purchased from the 
out-of-network (OON) provider on May 16, 2023.
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 based on the documentation provided, coverage 
criteria has not been met. The Plan denied your request. The Plan says the services are necessary.  
 
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.  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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration, edentulous area  resorbable 
barrier, per site (D7956), and bone replacement graft for ridge preservation - per site (D7953) provided on June 
22, 2023. 
 
You asked the Plan to pay for the guided tissue regeneration and bone replacement graft for ridge preservation. 
You say that you are seeking to be reimbursed for what you paid the provider. The Plan denied your request. 
The Plan says these services are not a covered expense under your dental plan. 
 
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 services are not among 
those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for guided tissue regeneration, edentulous area  
resorbable barrier, per site (D7956), and bone replacement graft for ridge preservation - per site (D7953) 
provided on June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for limited oral evaluation - problem focused (D0140), 
intraoral - periapical first radiographic image (D0220),extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided on May 23, 2023, to June 19, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are asking for the charges to be 
reviewed for additional coverage under the dental plan benefit. The Plan denied your request. The Plan says 
you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider.  
 
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. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 pay more for limited oral evaluation - problem focused 
(D0140), intraoral - periapical first radiographic image (D0220),extraction, erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) provided on May 23, 2023, to June 19, 2023.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Keytruda, Carboplatin and Paclitaxel. 
 
You asked the Plan to pre-approve Keytruda, Carboplatin and Paclitaxel. You say that the services are 
medically necessary. The Plan denied your request. The Plan says that this combination of drugs is 
recommended before surgery, the records show that the enrollee has already had surgery for their condition. 
 
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 Keytruda, Carboplatin and Paclitaxel. 
Our reviewer says that the medication is medically necessary. Our physician reviewer found most experts 
would include with chemotherapy if not received in the neoadjuvant setting in enrollees with stage II or higher 
disease such as this enrollee. She is a stage IIA. The documentation supports that the requested drug is safe and 
effective and otherwise reasonable and necessary for this enrollee. Therefore, the request for Keytruda, 
Carboplatin and Paclitaxel should be approved. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Keytruda, Carboplatin and Paclitaxel have been met. Therefore, we decided that 
the Plan has to pre-approve Keytruda, Carboplatin and Paclitaxel.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next test null strip. 
 
You asked the Plan to pre-approve Contour Next test null strip. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. 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 Contour Next test null strip. Therefore, we decided that the Plan does not have to pre-approve Contour Next 
test null strip.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Koya Dayspring (non-pneumatic) Active Compression 
Garment System (K1024, K1033). 
 
You asked the Plan to pre-approve a Koya Dayspring. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 Koya Dayspring. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was not documented to have tried and failed a standard pneumatic 
compression device. There was no contraindication to using the standard device for this enrollee. The Koya Dayspring does not yet have high quality literature supporting its use over standard pneumatic compression 
devices. Therefore, the Koya Dayspring will be considered not medically necessary 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 a Koya Dayspring have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Koya Dayspring (non-pneumatic) Active Compression Garment System (K1024, 
K1033).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for non-emergent transport services provided on May 12, 2023. 
 
You asked the Plan to pay for non-emergent transport services. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the non-emergency transport does not meet the criteria 
for coverage. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 
 
 
 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 non-emergent transport services. Our 
reviewer says that the services were not medically necessary. Our physician reviewer found the documentation 
does not support why other means of transport were contraindicated. The documentation does not support the 
need for equipment that only a fully equipped ambulance can provide for safe transport. The documentation 
does not support that the ambulance transport was medically reasonable or necessary, given that alternatives 
were available. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of non-emergent transport services have not been met. Therefore, we decided that 
the Plan does not have to pay for non-emergent transport services provided on May 12, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Evenity. 
 You asked the Plan to pre-approve Evenity. You say that the enrollee has osteoporosis and would like coverage 
for Evenity due to concerns with their potassium on alendronate and history of lumbar disc herniation. The 
Plan denied your request. The Plan says that the step therapy requirements have not been 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 Evenity. Our reviewer says that Evenity 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drugs Tymlos and teriparatide. Also, there is no indication that the Plan's required drugs would likely 
be less effective or likely 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 Evenity have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Evenity.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Humira. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. 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 pre-approve Humira.   
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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visits (90791, 90837, and 90834) to be provided 
by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve office visits to be provided by an OON provider. You say that the services 
are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to 
provide these services. Therefore, coverage criteria have not been met. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. 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 
office visits (90791, 90837, and 90834) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0482) provided April 7, 2023. 
 
You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the drug testing have been met. 
Medical records were not provided to verify the services provided.. Therefore, we decided that the Plan does 
not have to pay for the drug testing (G0482) provided April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new patient home visit, and advance care planning services 
provided on May 02, 2023. 
 
You asked the Plan to pay for a new patient home visit, and advance care planning services. You say that these 
services were medically necessary. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a new patient home 
visit, and advance care planning services provided on May 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation with field of 
view of one full dental arch  maxilla, with or without cranium (D0366) provided on April 18, 2023. 
 
You asked the Plan to pay for the dental service. The Plan denied your request. The Plan says your benefit for 
the requested service $1,000 dollar limit was met. The Plan also says that the cone beam CT capture and 
interpretation is excluded from coverage and it 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 cone beam CT capture and 
interpretation is not among those covered under this benefit.  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your $1,000 annual maximum allowance benefit for the cone beam CT capture and interpretation 
exhausted on date of service January 16, 2023. Therefore, we decided that the Plan does not have to pay for the 
cone beam CT capture and interpretation with field of view of one full dental arch  maxilla, with or without 
cranium (D0366) provided on April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy (D3330) for tooth #18 provided 
on May 2, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you were referred by an in-network 
provider to complete the root canal. 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 the Plan paid $169 for dental services on February 6, 2023. On March 7, 2023, the Plan paid $102 for 
dental services. On May 2, 2023, the Plan paid $1,729 for dental services. For the year of 2023 the Plan paid 
$2,000 ($169 paid + $102 paid + $1,729 paid) for dental services; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of May 2, 2023. Therefore, we decided that 
the Plan does not have to pay more for the endodontic therapy (D3330) for tooth #18 provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
June 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental 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. 
 
 
  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 a 
comprehensive periodontal evaluation (D0180) provided June 13, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued inpatient mental health treatment. 
 
You asked the Plan to pre-approve continued inpatient mental health treatment. 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 inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 continued inpatient mental health 
treatment. Our reviewer says that the services are not medically necessary. Our physician reviewer found based 
upon review of the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of July 12, 2023, forward and could have been treated in a 
lesser restrictive setting. The enrollee was not showing any suicidal or homicidal ideation, auditory or visual 
hallucinations, or delusions and was not showing any behaviors or aggression. The enrollee was being 
cooperative and compliant while not showing any acute threats to safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient mental health treatment have not been met. Therefore, we 
decided that the Plan does not have to pre-approve continued inpatient mental health treatment.