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

We decided that the Plan does not have to pay for the intraoral x-ray and limited oral evaluation provided on
March 12, 2020.
You asked the Plan to pay for the intraoral x-ray and limited oral evaluation. You say that the dentist was in-network
when you signed up for the plan. The Plan denied your request. The Plan says out-of-network dental
services are not covered benefits.
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, out-of-network dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
intraoral x-ray and limited oral evaluation provided on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for the air purifier purchased on April 5, 2020. 
 
You asked the Plan to reimburse for the air purifier. You say that you are requesting reimbursement of services 
rendered. The Plan denied your request. The Plan says Medicare guidelines say that air cleaners are not covered 
as they are not medical in nature. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to reimburse for the air purifier purchased on April 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, erupted tooth or exposed root (elevation and/or 
forceps removal) (D7140 x 4) and alveoloplasty in conjunction with extractions - four or more teeth or tooth 
spaces, per quadrant (D7310) provided on March 20, 2020. 
 
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the 
denied charges. The Plan denied your request. The Plan says you exhausted your 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. 
 
Review of the file show that you received a total of seven (7) dental extractions on March 20, 2020. The Plan 
paid for three (3) dental extractions based on your dental benefits. Your EOC states, Extractions (Pulling 
Teeth) ? Frequency/Limitations - Three (3) procedures per calendar year. Therefore, you are responsible for the 
four (4) dental extractions (D7140 x 4). Furthermore, alveoloplasty in conjunction with extractions - four or 
more teeth or tooth spaces, per quadrant (D7310) is not a covered benefit. Therefore, we decided that the Plan 
does not have to pay for extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140 x 
4) and alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant (D7310) 
provided on March 20, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pre-approve continued inpatient psychiatric hospital care after August 10, 2020 
for the enrollee. 
 
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that these services are 
medically necessary for the enrollee. The Plan denied your request. The Plan says that that the request is not 
medically necessary because the records received do not show a reason for approval or denial. 
 
The Plan must follow Medicare rules. Before discharging an enrollee from an inpatient hospital level of care, 
Medicare rules say that the Plan must obtain concurrence from the physician who is responsible for the 
enrollee's inpatient care. 
 
In this case, the record does not show that the physician responsible for the enrollee's inpatient care concurs 
with this discharge. Therefore, we decided that the Plan has to pre-approve continued inpatient psychiatric 
hospital care after August 10, 2020 for the enrollee.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional trips 
to attend medical appointments. The Plan denied your request. The Plan says that you have exceeded the 
benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of twelve (12) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME provided to the enrollee on May 15, 2019 by an 
out-of-network provider. 
 
You asked the Plan to pay for the DME. You say that the durable medical equipment is medically necessary. 
The Plan denied your request. The Plan says the services provided are not urgent or emergent there was ample 
enough time to request prior authorization. The Plan states it is the responsibility of the provider and the 
member to verify benefits and coverage prior to rendering or receiving 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 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 has network providers 
available who can provide 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 DME provided to the enrollee on May 15, 
2019 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says this drug is not 
medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 pre-approve Keytruda. Our reviewer says that 
Keytruda is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found 
that the requested use of Keytruda is not FDA approved or supported by any of the CMS approved compendia. 
There are no supporting citations in a PubMed search. Therefore the submitted documentation does not support 
that Keytruda is medically reasonable and necessary, nor that it is safe and effective 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 Keytruda have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Keytruda.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the lower level of skilled nursing care cannot provide 
the needed services. The Plan denied your request. The Plan says it is not reasonable to expect that the enrollee 
will be able to fully participate in the intensity of services of an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that the enrollee is generally medically stable with debility after abdominal surgery, with no recent neurological 
or orthopedic events. There is no evidence of complex medical issues that require monitoring by an inpatient 
rehab physician three times per week, or a need for acute rehab nursing care. While the enrollee may benefit 
from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy 
program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to 
rehabilitation care. Therefore, an admission to an IRF is not medically necessary, based on lack of medical 
complexity. 
 
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 heavy duty Group 3 power wheelchair. 
 
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says the 
enrollee does not have a medical need for the multiple power options, tilt and recline, included with the 
requested wheelchair. An expandable control system is not necessary as there is no medical need to control 
more than 2 power options through a joystick. 
 
The Plan follows Medicare rules. Medicare rules say that power mobility devices are only covered under 
certain medical indications. 
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 wheelchair. Our physician 
reviewer found that the documentation does not indicate the enrollee is at high risk for development of a 
pressure ulcer and is unable to perform a functional weight shift; that the patient uses intermittent 
catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or 
that the enrollee needs to manage increased tone or spasticity. The expandable control system is not medically 
reasonable and necessary to operate the requested power tilt and recline features. She does not need a ventilator 
or for two power options: power tilt and power recline. She does not require another proportional input device, 
a non-proportional input device, 3 or more actuators controlled through drive control, a separate display, other 
electronic devices or attendant control. Therefore, the requested heavy duty power wheelchair and related 
accessories 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 the requested wheelchair have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a heavy duty Group 3 power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. The Plan denied your request. The Plan says the 
enrollee is able to ambulate long distances using a cane, and is able to complete MRADLS in the home. 
 
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 patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair. Our physician 
reviewer found that you have a history of falls, muscle weakness, gait abnormality, and decreased endurance. 
You are independent with grooming, and moderately independent is activities of daily living. You are noted to 
have bilateral upper extremity full function to propel a manual wheelchair. You can ambulate over 1000 feet 
with a straight cane, to facilities cafeteria from apartment and back safely, without gait deficits. Inside your 
apartment you use a cane for long distances. You have a personal mobility deficit, but it does not impair 
participation in MRADLs in the home. Your mobility deficit can be helped by a cane or manual wheelchair. 
The documentation does not indicate that you would be unsafe using a power wheelchair, however, this device 
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 a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for genetic testing provided on March 26, 2020. 
 
You asked the Plan to pay for genetic tests. You say that the in-network treating physician ordered these tests 
as medically necessary to provide the best care for the enrollee. The Plan denied your request. The Plan says 
that the denial of payment for these services is correct, because these tests were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a 
contract provider are considered approved by the plan unless notice is provided that the services will not be 
covered. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-
of-network with the Plan. The documentation submitted does not include prior notice from the Plan that these 
tests would not be covered. Without this information, we cannot determine whether the lab order made 
constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for these 
services is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for genetic 
testing provided on March 26, 2020.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Privigen for the enrollee. 
 
You asked the Plan to pre-approve Privigen. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says the records do not show that the member has tried and failed steroids. 
 
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 Privigen. Our reviewer says that 
Privigen is not medically reasonable and necessary for the enrollee. The FDA has not approved the use of this 
medication in the enrollee's diagnosis. IVIG is not currently recommended for use in any of the Medicare 
accepted Compendia. The use of this drug is not indicated/supported/listed within the Medicare accepted 
Compendia. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 
Privigen. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Privigen for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an exception to the 75 mile limit for routine 
transportation. 
 
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you need additional miles 
to get to medical appointments. The Plan denied your request. The Plan says that your request exceeds the 
benefit limit. 
 
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits 
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we 
decided that the Plan does not have to pre-approve an exception to the 75 mile limit for routine transportation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that inpatient rehab will assist the individual to achieve 
maximum functional capacity. The Plan denied your request. The Plan says the enrollee's care is not complex. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 physician reviewer found 
that the enrollee is generally medically stable after a right hip fracture with an uncomplicated post-op course, 
and no recent neurological or other events. There is no evidence of complex medical issues that require 
monitoring by an inpatient rehab physician three times per week, or a need for acute rehab nursing care. While 
the enrollee may benefit from continuing physical and occupational therapy, there is no evidence of need for an 
intensive therapy program with therapy 3 hours per day with frequent physician oversight and an 
interdisciplinary approach to rehabilitation care. Therefore, an admission to an IRF is not medically necessary, 
based on lack of medical complexity. 
 
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that an ambulance was called on the date of service after the enrollee experienced a minor car accident. You say that the ambulance responders only took the enrollee's blood pressure and then the enrollee refused transportation because he was not injured. You stated that you have now received a bill from the ambulance company for the services. You say that you are appalled by the charges and you asked the Plan to reconsider providing coverage for the services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on July 16, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services provided on July 25, 2019. 
 
You asked the Plan to pay for the surgical assistant services. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services billed are not payable. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of 
practitioners. Therefore, we decided that the Plan does not have to pay for the surgical assistant services 
provided on July 25, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Gammagard liquid injection.
You asked the Plan to pre-approve Gammagard liquid injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested drug is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Gammagard liquid injection is only covered for certain indications. 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 Gammagard liquid injection. Our reviewer says that the documentation supports that the requested Gammagard liquid injection is medically reasonable and necessary. Our physician reviewer found the enrollee has myeloma and is status post-transplant in 2015. The documentation shows the enrollee is in stable phase. LCD L34007 is silent for myeloma. The requested Gammagard liquid injection is continuation of IV IG. Micromedex supports the Gammagard liquid injection as the enrollee is plateau phase of myeloma. Therefore, the enrollee meets 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 Gammagard liquid injection have been met. Therefore, we decided that the Plan has to pre-approve Gammagard liquid injection.
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.