Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says a second diagnostic injection is needed to be able to approve the request. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has had only one set of diagnostic medial branch blocks. The criteria requires dual 
diagnostic blocks. Therefore, at this point, the request is deemed not medically reasonable or necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve radiofrequency ablation for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for PT provided on August 17, 2020. 
 
You asked the Plan to waive the copayment for PT. You say that you disagree with the charges because you 
were told insurance would cover PT. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
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 $35 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $35 copayment for PT. PT falls within the outpatient rehabilitation 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 copayment for PT provided on August 17, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the placement of endosteal implants (D6010 x 2), the bone 
graft at the time of implant placement (D6104) provided on July 23, 2020. 
 
You asked the Plan to pay for the implants and bone graft. You say that you received these services purely for 
function. You say that the services were needed as a result of your fractured tooth. The Plan denied your 
request. The Plan says implants are not listed as a covered service. The Plan says bone graft is not listed as a 
covered service either. 
 
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 pay for the 
placement of endosteal implants (D6010 x 2), the bone graft at the time of implant placement (D6104) 
provided on July 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bupivicaine hydrochloride injection (S0020) provided on 
May 28, 2020. 
 
You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says CPT code S0020 has a status indicator of I and is not 
valid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code S0020 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT 
code S0020 has a status indicator of I. This means that CPT code S0020 is not valid for Medicare purposes. 
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 pay for the bupivicaine hydrochloride injection (S0020) 
provided on May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this was an emergency 
service. You also say that you needed the problem focused exam so the provider could determine the extent of 
your needs. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your 
benefit plan. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation (D0140) on January 15, 2020, and your problem focused limited oral evaluation 
(D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem 
focused limited oral evaluation (D0140) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on March 13, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this service was 
rendered as part of an urgent visit. The Plan denied your request. The Plan says this service is not covered. 
 
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 pay for the 
problem focused limited oral evaluation (D0140) provided on March 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient surgery provided by a non-
participating provider on July 7, 2020. 
 
You asked the Plan to waive the deductible for an outpatient surgery. You say that you can't control how things 
are billed. The Plan denied your request. The Plan says the correct deductible has been applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $750 deductible.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible for an outpatient surgery. This cost sharing is a contractual obligation that had not been met at the 
time an outpatient surgery was received on July 7, 2020. The total amount you are being asked to pay is 
$129.13. Therefore, we decided that the Plan does not have to waive the deductible for an outpatient surgery 
provided by a non-participating provider on July 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with altered mental status and was felt to be at baseline after imaging and a 
neurosurgery consultation. He is medically stable and does not require services at the LTACH that are not 
already available at the current hospital. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current hospital. The LTACH services are not reasonable or 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on June 23, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
provided by a physician. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. The requested acupuncture services were not provided by a 
qualifying practitioner or under the supervision of a qualifying practitioner. Based on this information, we 
decided that the rules for coverage of the acupuncture services have not been met. Therefore, we decided that 
the Plan does not have to pay for the acupuncture services provided on June 23, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 13 additional home health visits. 
 
You asked the Plan to pre-approve the additional home health visits. You say that you would like 
reconsideration because the additional home health visits are medically necessary. The Plan denied your 
request. The Plan says there is no indication that the approved home health services were performed or that the 
member was re-evaluated. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 additional home health visits. Our 
reviewer says that the documentation does not support that the member requires skilled nursing services to 
provide treatment that is medically necessary. Our physician reviewer found the member does not require 
skilled nursing to effectively provide treatment, care, and/or services in order to improve the member?s 
 
 
condition, perform a maintenance program to maintain the members condition and/or prevent deterioration.  
The member has been medically stable without any recent exacerbations of chronic medical problems or 
hospitalizations. 
 
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 additional home health visits have not been met. Therefore, we decided that 
the Plan does not have to pre-approve 13 additional home health visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 17, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must 
receive care from in-network providers with the exception of emergency or urgent care, dialysis while 
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which 
requires prior authorization from the plan.  
 
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 did not pre-approve the 
physician's services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on June 17, 2020.
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 for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's therapy and medical needs can safely be met at a lower 
level of care. 
 
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 reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to 
require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care 
needs can be met at a lower level of care. Our physician reviewer found that the enrollee's condition does not 
meet Medicare criteria for IRF care. 
 
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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued use of a continuous positive airway pressure 
device (CPAP). 
 
You asked the Plan to pre-approve continued CPAP use. You say that this is medically necessary. The Plan 
denied your request. The Plan says that the enrollee has not been compliant with the CPAP. 
 
The Plan must follow Medicare rules. Medicare rules say that you must use the PAP 4 hours per night on 70% 
of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 
 
We looked at the file and Medicare rules. The compliance report included with the file indicates the enrollee 
did not adhere to therapy. Based on this information, we decided that Medicare rules for coverage of continued 
CPAP use have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use 
of a continuous positive airway pressure device (CPAP).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fluorouracil (J9190), Leucovorin (J0640), and 
Oxaliplatin (J9263) injections. 
 
You asked the Plan to pre-approve Fluorouracil, Leucovorin, and Oxaliplatin. You say that these drugs are 
medically necessary to treat the enrollee's condition. The Plan denied your request. The Plan says they have 
denied this service because the treatment is not recommended by the National Comprehensive Cancer Network. 
 
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 Fluorouracil, Leucovorin, and 
Oxaliplatin. Our reviewer says that these drugs are not medically necessary and reasonable to treat the 
enrollee's condition. Our physician reviewer found these drugs are only FDA-approved for stage III colon 
cancer. In addition, the use is not supported by one of the major drug compendia or by clinical research that 
appears in a CMS-approved medical journal as these drugs are only supported for high risk stage II disease and 
this patient does not have any adverse features. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Fluorouracil, Leucovorin, and Oxaliplatin have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Fluorouracil (J9190), Leucovorin (J0640), and Oxaliplatin 
(J9263) injections.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on July 20, 2020. 
 
You asked the Plan to waive the copayment for emergency care. You say that you waited for over an hour in 
the exam room but no doctor came so you left. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
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 $90 
copayment for emergency care.  
 
You have been asked to pay the allowed amount of $61.92, which is less than the $90 copayment for 
emergency care. Emergency care falls within the emergency care benefit category. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for emergency care provided on July 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy visits 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says detail is lacking in the skills that require PT intervention. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 services. Our reviewer says that 
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee appears to have plateaued with therapy. Further therapy at 
this point does not appear to be likely to achieve any significant improvement in symptoms or functional status. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve physical therapy visits
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) for prostate 
cancer. 
 
You asked the Plan to pre-approve the PBRT services. You say that the Plan is mistaken in this denial because 
there is an abundance of evidence to support the use of PBRT for prostate cancer. The Plan denied your 
request. The Plan says NCCN and ASTRO guidelines recommend the use of PBT for the treatment of non-
metastatic prostate cancer for individuals enrolled in an institutional board review approved study or a multi -
institutional registry that adheres to Medicare requirements for CED. The enrollee is not enrolled in a study, 
trial, or CED for evidence development. 
 
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 PBRT services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the National Comprehensive Cancer Network (NCCN) released a statement in the 
most recent guidelines which says that "there is no clear evidence supporting a benefit or decrement to proton 
therapy over IMRT for either treatment efficacy or long-term toxicity. Conventionally fractionated prostate 
proton therapy can be considered a reasonable alternative to X-ray based regimens". The American Society of 
Radiation Oncology (ASTRO), as part of the ?Choosing Wisely? campaign, recently released the following 
statement about proton therapy for prostate cancer, which states that PBRT should not be routinely 
recommended outside of a prospective clinical trial or registry, and 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. 
 
To date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than 
intensity modulated radiation therapy and image-guided radiation therapy (IMRT/IGRT). The generally 
accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not 
routinely offer it to patients. As such, the requested treatment is not considered medically reasonable and 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the PBRT services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve proton beam radiation therapy (PBRT) for prostate cancer.