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

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI).  
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met.  
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that you do not have an 
eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to pre-
approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from December 27, 2022, 
to December 29, 2022. 
 You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and the rules. The claim was billed with a type of bill 324. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the home health services provided from December 27, 2022, to December 
29, 2022.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Prolia (J0897). 
 You asked the Plan to pre-approve Prolia. You say that Prolia is a medical necessity for the enrollee. The Plan 
denied your request. The Plan says step-therapy rules for coverage of Prolia 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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial 
of generic oral bisphosphonates and of zoledronic acid before they will approve the requested drug. In this 
case, the enrollee has not tried and failed the required drugs. 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. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve treatment with Prolia (J0897).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vedolizumab (Entyvio) Injection (J3380). 
 
You asked the Plan to pre-approve the Vedolizumab (Entyvio) Injection . You say that the item is medically 
necessary. The Plan denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved 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 the Vedolizumab (Entyvio) Injection. 
Our reviewer says that the item is not medically necessary. Our physician reviewer found provided records do 
not document the patient in this case has had inadequate response with lost response to, or was intolerant to a 
tumor necrosis factor blocker or immunomodulator; or had inadequate response with, was intolerant to, or 
demonstrated dependence on corticosteroids. The use of vedolizumab is not supported by one of the major drug 
compendia or by clinical research that appears in a CMS-approved medical journal without documentation of inadequate response with, lost response to, or intolerance to a tumor necrosis factor blocker or 
immunomodulator; or inadequate response with, or intolerance, or demonstrated dependence on 
corticosteroids. 
 
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 Vedolizumab (Entyvio) Injection have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Vedolizumab (Entyvio) Injection (J3380).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room visit coded as 99283, 87804, 87811 
provided January 4, 2023. 
 
You asked the Plan to pay for the emergency services. You say that you request reconsideration of your claim 
for additional payment as the services rendered were emergency services what were medically necessary. The 
Plan denied your request. The Plan says this provider is not certified with Medicare. 
 
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 emergency room visit coded as 
99283, 87804, 87811 provided January 4, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services, ophthalmic diagnostic imaging, a 
bevacizumab injection, and an intravitreal injection provided on October 24, 2022. 
 
You asked the Plan to pay for ophthalmological services, ophthalmic diagnostic imaging, a bevacizumab 
injection, and an intravitreal injection. 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 ophthalmological 
services, ophthalmic diagnostic imaging, a bevacizumab injection, and an intravitreal injection provided on 
October 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for each tissue pathology service provided on 
January 09, 2023. 
 
You asked the Plan to waive the coinsurance for each tissue pathology service. You say that you were quoted a 
$0 cost for these services. 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 10% 
coinsurance for diagnostic tests, including tissue pathology services.  
You have been asked to pay 10% coinsurance for each tissue pathology service. This item/service falls within 
the diagnostic tests, including tissue pathology 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 coinsurance for each tissue pathology service provided on January 09, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for each radiation therapy service provided on 
July 07, 2022, to August 03, 2022. 
 
You asked the Plan to reduce the copayment for each radiation therapy service. You say that you were told this 
would cost around $800. 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 $50 
copayment for outpatient radiation therapy services. 
 
You have been asked to pay a $50 copayment for each radiation therapy service. This item/service falls within 
the outpatient radiation therapy 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. Due to meeting your out-of-pocket maximum, you have only been asked to 
pay $22.19 for the radiation therapy services provided on July 27, 2022. Therefore, we decided that the Plan 
does not have to reduce the copayment for each radiation therapy service provided on July 07, 2022, to August 
03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown-porcelain (D2750) and core buildup (D2950). 
 
You asked the Plan to pre-approve a crown and core buildup. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary because the records indicate that crown 
and core buildup is not indicated for a tooth that does not have a loss of tooth structure or a previous root canal. 
 
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 a crown and 
core buildup 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 a crown and core buildup. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found a review of the documentation indicates the presence of a crown on tooth #20 which appears adequate. There was no documentation indicating 
why a replacement crown was necessary. 
 
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 a crown and core buildup have not been met. Therefore, we decided that the 
Plan does not have to pre-approve crown-porcelain (D2750) and core buildup (D2950).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Luspatercept-aamt. 
 You asked the Plan to pre-approve Luspatercept-aamt. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested drug does not meet step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Luspatercept-aamt. Our reviewer says 
that the documentation does not support that the requested drug meets step therapy criteria. Our physician 
reviewer found the enrollee has a diagnosis of Chronic myeloproliferative disease. The enrollee has 
myelofibrosis with anemia. The documentation does not support that the enrollee has tried and failed 
erythropoiesis-stimulating agents, such as epoetin alfa (Epogen, Procrit) and darbepoetin alfa (Aranesp). The 
documentation does not support that erythropoiesis-stimulating agents, such as epoetin alfa (Epogen, Procrit) 
and darbepoetin alfa (Aranesp) would likely be less effective, and/or would likely have adverse effects for the 
enrollee in this case. Therefore, the enrollee does not meet criteria for the requested drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Luspatercept-aamt have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Luspatercept-aamt.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the special services provided on October 12, 2022 
 
You asked the Plan to pay for the special services. You say that you purchased progressive lenses and frames 
and submitted forms requesting reimbursement. The Plan denied your request. The Plan says that your 
coverage excludes out-of-network services. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by an out-of-network provider. 
 
We looked at the file and the Plan's rules. Specifically, you have out-of-network vision benefits and you do not 
require a referral for out-of-network services. Based on this information, we decided that the Plan's rules for 
coverage of the special services have been met. Therefore, we decided that the Plan has to pay for the special 
services provided on October 12, 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: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Myobloc injections. 
 
You asked the Plan to pre-approve the injections. You say that the enrollee did not try Xeomin or Botox and 
none of them would be appropriate for the enrollee as, "In clinical experience Myobloc more effective and lasted longer than other formulation". You state that trying Botox or Xeomin first could result in 
ineffectiveness and delays in the enrollee's quality of life. The Plan denied your request. The Plan says the 
provider stated that the enrollee has not tried and failed both preferred products of Botox and Xeomin 
injections. The Plan states the enrollee's provider did not provide enough documentation showing why Botox 
and Xeomin would not be suitable for the enrollee. 
 
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 the injections. Our physician reviewer 
found the Plan requires the enrollee must have tried and failed to have an adequate response to both Botox and 
Xeomin injections, before they will approve the requested drug. In this case, the enrollee has not tried and 
failed the required drug(s). There is no documentation provided indicating that the Plans required drug(s) 
would likely be less effective and/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 the injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Myobloc injections.
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 enrollee meets Medicare criteria for IRF and that 
the necessary care cannot be provided at a lower level. The Plan denied your request. The Plan says that the 
enrollee does not meet Medicare guidelines for admission. 
 
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 that 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 does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345 billed for date of service June 1, 2022. 
 You asked the Plan to pay for procedure code 81345. You say that please see attached appeal with 
documentation that supports medical necessity. The Plan denied your request. The Plan says payment for code 
81345 is bundled into payment for code 0089U. 
 
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 81345 
is a column II code to column I code 0089U. 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 81345 billed for date of service June 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system identified with code 
E2300 and electronic connection between wheelchair controller and one power option identified with code 
E2310. 
 
You asked the Plan to pre-approve a power seat elevation system and electronic connection between 
wheelchair controller and one power option. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested items are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation systems are not covered. 
The rules also say that electronic connections are only covered for certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the requested power seat elevation 
system is specifically not covered. The electronic connection is not covered because the documentation does 
not support a medical need to control the power options through the joystick. The power option can be 
controlled using its own switch. Based on this information, we decided that Medicare rules for coverage of a 
power seat elevation system and electronic connection between wheelchair controller and one power option 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation 
system identified with code E2300 and electronic connection between wheelchair controller and one power 
option identified with code E2310.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Durolane injection (J7318). 
 
You asked the Plan to pre-approve the injection. You say that the medication is medically necessary. The Plan 
denied your request. The Plan says the notes do not say the enrollee has tried a first line medication or preferred medication like Monovisc or Synvisc-One. The Plan states the notes do not say the enrollee has tried a first line 
medication and that it did not help, or the enrollee cannot take a first line medication. 
 
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 the injection. Our physician reviewer 
found the Plan requires a trial of drug Monovisc or Synvisc-One, before they will approve the requested drug. 
In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided 
indicating that the Plans required drug(s) would likely be less effective and/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 the injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Durolane injection (J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Zoster (Shingles) vaccine provided on February 23, 2023. 
 
You asked the Plan to pay for Zoster vaccine. You say that it is medically necessary. The Plan denied your 
request. The Plan says the vaccine and its administration are covered under your pharmacy benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Zoster vaccine. The 
Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Zoster vaccine. 
Therefore, we decided that the Plan does not have to pay for a Zoster (Shingles) vaccine provided on February 
23, 2023.  
 
Benefits for Zoster vaccine may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.