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

 
We decided that the Plan does not have to pre-approve two guided tissue regenerations (D4267 x2), endosteal 
implant (D6010), and two bone replacement grafts for ridge preservation (D7953 x2). 
 
You asked the Plan to pre-approve the guided tissue regenerations, endosteal implant, and bone replacement 
grafts. You say that you need these services to be provided to you. The Plan denied your request. The Plan says 
these services are not covered under your benefit package. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two 
guided tissue regenerations (D4267 x2), endosteal implant (D6010), and two bone replacement grafts for ridge 
preservation (D7953 x2).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the SNF stay provided from February 25, 
2019 through March 8, 2019 and July 1, 2019, through July 10, 2019.  
 
You asked the Plan to waive the copayment for the SNF stays. You say that out of pocket costs have exceeded 
the policy limit. The Plan denied your request. The Plan says the copayments applied 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). The enrollees contract with the Plan clearly says that enrollees 
must pay a $20 copayment per day, days 1 to 20 and a $172 copayment per day, days 21 to 100 at an in-
network skilled nursing facility.  
 
The enrollee has been asked to pay a total of $400 for the SNF stays.  
 
Date of Service Number of Days Standard Copayment Member Liability 
February 25, 2019- 
February 28, 2019 
4 $20/Day $80 
March 1, 2019- 
March 8, 2019 
7 $20/Day $140 
July 1, 2019- 
July 10, 2019 
9 $20/Day $180 
TOTAL:   $400 
 
  
The SNF stays falls within the "Skilled nursing facility (SNF) care" benefit category. The records show that the 
out-of-pocket maximum had not been met at the time the services were received. This means that the enrollee 
has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual 
obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not 
have to waive the copayment for the SNF stay provided from February 25, 2019 through March 8, 2019 and 
July 1, 2019, through July 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Temozolomide for the enrollee. 
 
You asked the Plan to pre-approve this drug. You say that the enrollee has been stable on this medication. The 
Plan denied your request. The Plan says this is not covered under Part B. 
 
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 Temozolomide for the 
enrollee.  
 
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights. 
 
Please note, the Plan has approved Temozolomide under the enrolles Part D benefit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine you received on September 10, 2020. 
 
You asked the Plan to pay for the shingles vaccine. You say that you need this vaccine. The Plan denied your 
request. The Plan says this is not a covered benefit under your Part B plan. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. 
The Plan follows the same rules.  
 
The records do not show that you have been injured or directly exposed to any illness related to the shingles 
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine you received on 
September 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Revita Allograft (15275, 15271, Q4180). 
 
You asked the Plan to pre-approve these services. You say that your doctor is requesting this to speed up the 
healing process. The Plan denied your request. The Plan says that the clinical value and effectiveness of the 
Revita Allograft to speed up healing for a scalp lesion associated with malignant melanoma has not been 
demonstrated in the peer-reviewed literature. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. You are noted to 
have melanoma of the scalp, which has been previously biopsied and surgically excised. Wound care is 
ongoing. The documentation does not note that a Revita allograft is to be used, why it is necessary or why it 
would be superior to other types of wound care, including other grafts. Our physician reviewer found that your 
condition does not meet criteria for coverage of these services. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Revita Allograft (15275, 15271, Q4180).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology service provided on November 13, 2019.
You asked the Plan to pay for the molecular pathology service. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says this service has not been billed appropriately.
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 pay for the molecular pathology service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at this time, there is insufficient evidence in the peer-reviewed medical literature to establish that genetic testing is beneficial in terms of health outcomes in the clinical care of patients with age-related macular degeneration. 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 molecular pathology service have not been met. Therefore, we decided that the Plan does not have to pay for the molecular pathology service provided on November 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve these services. You say that finger prick testing is too painful. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific 
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 these services. Our reviewer says that 
you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you do 
not meet the criteria for coverage of a therapeutic CGM. The records support that you do not adjust your 
insulin dosage based on blood sugar level readings. You are not on a multi-dose regimen. The CGM is 
therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve the requested services. You say that proton therapy offers a better quality of 
life. The Plan denied your request. The Plan says there is no current research showing the enrollee's cancer 
responds better to proton therapy than the type of treatment the plan can approve. 
 
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 requested services. Our physician 
reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical 
advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a possible 
advantage of this expensive therapy. 
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam radiation therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electronic connection (E2311) for the enrollee. 
 
You asked the Plan to pre-approve an electronic connection. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the member's upper extremity strength and function are adequate to 
control the power options using their own switch which are included in the allowance of these power options. 
 
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 an electronic connection. Our reviewer 
says that the requested items is not considered medically reasonable and necessary in this case. Records 
indicate the enrollee is independent with feeding with 4+/5 left upper extremity strength and he appears to have 
left upper extremity strength and function to control the power options using their own switches. Our physician 
reviewer found that the enrollee's condition does not meet Medicare criteria for an electronic connection. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an electronic connection have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an electronic connection (E2311) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Influenza virus vaccine services provided on October 15, 
2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the Influenza virus vaccine services. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 
benefit. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the Influenza virus vaccine services provided on 
October 15, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist services. You say that you would like this approved for an out-of-
network provider. The Plan denied your request. The Plan says there are in-network providers available for 
these services. 
 
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 
specialist services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on July 6, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the home visit (99349). You say that you would like reconsideration because 
authorization for telemedicine services is no longer required. The Plan denied your request. The Plan says these 
services were not urgent, emergent or approved in advance. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on July 6, 2020, by 
an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for replacement tips for your cane. 
 
You asked the Plan to pay for the replacement tips. You say that you would like reconsideration because you 
have received replacements in the past and this should be a covered benefit. The Plan denied your request. The 
Plan says Medicare does not cover duplicative durable medical equipment 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the replacement tips have not been met. Specifically, the record indicates that the Plan approved 
the quad point cane but you refused the equipment delivery. The plan states that the preferred brand/type is no 
longer available but that an equivalent cane was approved. There is no specific information given to support 
that the quad point cane approved by the plan cannot meet your needs. Therefore, we decided that the Plan does 
not have to pay for replacement tips for your cane.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain/ceramic (D6245) and retainer crown - 
porcelain/ceramic (D6740). 
 
You asked the Plan to pre-approve pontic - porcelain/ceramic and retainer crown - porcelain/ceramic. You say 
that these services are medically necessary. The Plan denied your request. The Plan says these services are not 
covered benefits under your supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
pontic - porcelain/ceramic (D6245) and retainer crown - porcelain/ceramic (D6740).
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a computed tomographic angiography (CTA) of the neck (70498). 
 
You asked the Plan to pre-approve a CTA of the neck. You say that the service was medically necessary. The 
Plan denied your request. The Plan says that clinical information received does not support the medical 
necessity of the requested imaging service. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for CTA of the neck. Our reviewer says that the 
service is medically necessary. Our physician reviewer found the report describes calcified ulcerative plaque on 
the left. The presence of such ulceration as well as stenosis approaching 70% are findings which support CTA 
of the neck. 
 
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 CTA of the neck have been met. Specifically, medical records show an 
ulceration making the CTA medically reasonable and necessary. Therefore, we decided that the Plan has to pre-
approve a computed tomographic angiography (CTA) of the neck (70498).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on February 28, 2020, by an 
OON provider. 
 
You asked the Plan to pay for nursing facility discharge. You say that the rendered services were medically 
necessary. The Plan denied your request. The Plan says rules for payment 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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the medical services provided on February 28, 
2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 
26, 2020 to June 9, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says assigning a diagnosis of sepsis in the context of this stay is not supported for this enrollee. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found treview 
has determined that the submitted documentation supported that the condition, after study, which occasioned 
the admission to the hospital was peritoneal abscess. The records provided do not indicate that this condition 
lead to sepsis (life-threatening organ dysfunction caused by a dysregulated host response to infection). 
Assigning a diagnosis of sepsis (or applying a code for sepsis) in the context of this stay is not supported. The 
correct DRG would be 372 - MAJOR GASTROINTESTINAL DISORDERS & PERITONEAL INFECTION.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate DRG . Therefore, we decided that the Plan does not have to pay for 
inpatient hospital services provided to the enrollee from May 26, 2020 to June 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung 
cancer screening. 
 
You asked the Plan to pre-approve the requested LDCT scan. You say that the service was medically 
necessary. The Plan denied your request. The Plan says your records show that you are being treated for lung 
cancer and you have had standard CT scans. These scans would have identified any other areas of cancer 
besides the one that is being treated. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung 
cancer screening for enrollees who meet all the above described criteria.  
 
We reviewed the file and the Medicare rules. We find that the absence of signs/symptoms of lung cancer 
criteria has not been met. Specifically, your records indicate you are being treated for lung cancer, this makes 
you ineligible for LDCT. This means the service is not covered.  Therefore, we decided that the Plan does not 
have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.