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

 
We decided that the Plan does not have to pre-approve the crowns (D2740) for teeth # 30 and 31. 
 
You asked the Plan to pre-approve the crowns (D2740). You say that the enrollee needs a crown to restore the 
tooth's shape and functionality. The Plan denied your request. The Plan says the services are not medically 
necessary. 
 
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. The Plan covers crowns 
(D2740) 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 the crowns (D2740). Our reviewer says 
that crowns are considered when there is extensive missing tooth structure due to decay or fracture. Our 
physician reviewer found that both teeth would be amenable to the placement of standard restorations. Our 
reviewer says that as there is no clear need for full coverage restorations, there is no medical necessity for the 
requested procedures. 
 
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 the crowns (D2740) have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the crowns (D2740) for teeth # 30 and 31.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee requires no skilled nursing which would be considered skilled services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically, and you are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You can receive further rehab at a lower level of care. You do not have any parenteral medication; complex wound care or nutrition given via a feeding tube. You have no acute exacerbations of chronic medical problems. Your physical function is at or near your baseline, and you can receive services at a lower level of 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Cardiac Computed Tomography Angiography (CTA) 
(75574). 
 
You asked the Plan to pre-approve the CTA. You say that the CTA is medically necessary. The Plan denied 
your request. The Plan says the requested procedure is not medically necessary. 
 
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 pre-approve the CTA. Our reviewer says that the 
requested cardiac CTA is not medically necessary. Our physician reviewer found a colonoscopy is a very low 
risk non-cardiac procedure that does not require pre-procedure stress testing.  The stress test results were 
unequivocally normal by lack of symptoms and perfusion imaging. f an assessment of coronary anatomy is 
thought to be needed then coronary angiography is preferred due to improved accuracy relative to CT 
angiography and the ability to intervene with revascularization during the same procedure if indicated. 
 
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 CTA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Cardiac Computed Tomography Angiography (CTA) (75574).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says there are medical issues that can be adjusted and addressed in the primary 
hospital. 
 
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 considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to require additional acute care services for the short term to 
allow for education, placement, and additional antibiotics, however, less than an additional 25 days of acute 
care services is likely. The enrollee does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH that the enrollee requires that is not available and covered 
at the current facility. Therefore, this request for LTACH services will be considered not medically necessary. 
Transfer to a lower level of care may be considered soon. 
 
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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950). 
 
You asked the Plan to pre-approve the core buildup (D2950). You say that the tooth broke and it bothers you to 
eat. You say that the procedure should be paid for because it is an emergency. The Plan denied your request. 
The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
core buildup (D2950).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional home health aide hours. 
 
You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan 
denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 additional hours. Our reviewer says 
that the requested additional hours are not medically reasonable or necessary. Our physician reviewer found 
you are noted to not be homebound. You are not shown to have skilled nursing needs, or skilled therapy needs. 
Your care needs appear to be custodial. As such, the documentation does not show that these services are 
medically necessary, or coverable. 
 
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 hours have not been met. Therefore, we decided that the Plan 
does not have to pre-approve additional home health aide hours.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable home ventilator and heated humidifier. 
 
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan 
denied your request. The Plan says that ventilators used to provide CPAP or bi-level CPAP therapy will be 
denied as not reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 a 
portable home ventilator is not medically reasonable and necessary. You are noted to have COPD. There is no 
evidence that you have a thoracic restrictive disease or a neuromuscular disease. You use home oxygen. There 
is no evidence that you use, or have ever tried using, a home CPAP or BiPAP machine. A recent ABG, 
completed while you were on supplemental oxygen, showed a mildly elevated pCO2. Our physician reviewer 
found that your condition does not meet Medicare criteria for a portable home ventilator. 
 
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 portable home ventilator and heated humidifier.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a powered pressure-reducing air mattress. 
 
You asked the Plan to pre-approve the mattress. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no clinical lesions on the skin that would be amenable to the use of this 
requested durable medical equipment. 
 
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 mattress. Our reviewer says that the 
requested mattress is not considered medically reasonable and necessary in this case. Our physician reviewer 
found the case file does not contain documentation that the enrollee has multiple stage II pressure ulcers 
located on the trunk or pelvis, or large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis, or a 
myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days and has been 
on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the 
past 30 days. 
 
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 mattress have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a powered pressure-reducing air mattress.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve wheelchair back canes for the enrollee. 
 
You asked the Plan to pre-approve the canes. You say that this is needed due to the enrollee's considerable 
fatigue related to chronic medical issues. The Plan denied your request. The Plan says these back canes were 
requested for the convenience of a caregiver. 
 
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 pre-approve wheelchair back canes for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lift (E1399). 
 
You asked the Plan to pre-approve the lift. You say that you need the lift to get a wheelchair in and out of your 
home. The Plan denied your request. The Plan says lifts are not covered items. 
 
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 pre-approve a lift (E1399).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pembrolizumab (J9271). 
 
You asked the Plan to pre-approve pembrolizumab. You say that the requested medication is necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. The rules say that 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 pembrolizumab. Our reviewer says that 
the medication is not medically necessary. Our physician reviewer found based on the documentation provided, 
coverage criteria has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of pembrolizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve pembrolizumab (J9271).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that this is medically necessary for you. The Plan denied your request. The Plan says that your needs can be safely and better managed in a less restrictive setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal and core buildup on tooth 11.
You asked the Plan to pre-approve these services. You say that you need the dental treatments. The Plan denied your request. The Plan says the 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, 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 a root canal and core buildup on tooth 11.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from
January 30, 2019 to April 8, 2019 billed with code S9328.
You asked the Plan to pay for the HIT services. You say that these are medically necessary services and should
be covered. The Plan denied your request. The Plan says these services are billed with an invalid code.
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 S9328 is not supported. This code has a status indicator of "I" on the Physician Fee
Schedule which means it is invalid for Medicare purposes. Based on this information, we decided that
Medicare rules for coverage of the HIT services have not been met. Therefore, we decided that the Plan does
not have to pay for the home infusion therapy (HIT) services provided from January 30, 2019 to April 8, 2019
billed with code S9328.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to waive the deductible for a balance test involving hot and cold irrigation of the ears (92537) performed on May 15, 2020.
You asked the Plan to waive the deductible for a balance test. You say that you had fulfilled the annual deductible prior to the May 15, 2020 date of service. The Plan denied your request. The Plan says that the correct cost-sharing was 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 enrollees must pay a $10 copayment for diagnostic lab services and diagnostic procedures and tests performed in the outpatient department of a hospital. The Plan says you must pay $115.18 toward a $750 deductible for a balance test. The Plan contract, however, states that the deductible does not apply to some services, such as labs and diagnostic procedures/tests (excludes basic and advanced diagnostic imaging services). We further noted that services subject to the deductible are specifically noted as such throughout the contract. Diagnostic lab services and diagnostic procedures and tests performed in the outpatient department of a hospital are not stated to be subject to the deductible within the Outpatient Hospital Services benefit category. Based on the Plan contract, you cannot be asked to pay more than a $10 copayment for a balance test. Therefore, we decided that the Plan has to waive the deductible for a balance test involving hot and cold irrigation of the ears (92537) performed on May 15, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on January 24, 2020 by
an OON provider.
You asked the Plan to pay for the resin-based composite. You say that you have been with this dentist for 30
years and will not change dentists. You also say that the $1,000 dental benefit is no good to you. The Plan
denied your request. The Plan says the treating provider is not in the Plan's network.
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
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the resinbased
composite provided on January 24, 2020 by an OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on January 13, 2020.
You asked the Plan to pay for the definitive drug testing. You say that this testing was medically necessary. The Plan denied your request. The Plan says there is no evidence that this patient was seen by the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided on January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 3, 2020 billed
with code 99226.
You asked the Plan to pay for the medical services. You say that this was correctly billed and should be paid
for the neurology consultation provided. The Plan denied your request. The Plan says no payment can be made
for subsequent observation care to this provider as this provider did not order the observation care services for
this patient.
The Plan must follow Medicare rules. Medicare rules say that only the physician who orders observation care is
allowed to bill for initial and subsequent observation codes. All other physicians who furnish consultations or
additional evaluations or services while the patient is receiving hospital outpatient observation services must
bill the appropriate outpatient service codes.
As this provider did not order the observation services, no hospital observation codes can be paid for these
services. Therefore, we decided that the Plan does not have to pay for the medical services provided on
February 3, 2020 billed with code 99226.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the right knee x-ray examination provided on March 4, 2020.
You asked the Plan to pay for the right knee x-ray. You say that the documentation supports that this imaging was provided and is medically necessary. The Plan denied your request. The Plan says the documentation does not include a report of the right knee x-ray.
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient documentation to support that Medicare coverage criteria are met. In this case, the original case file did not include documentation of any imaging. In the documentation subsequently received directly from the provider, imaging of the knee was included; however, the date of service noted for this imaging was in 2019. As such, we still do not have documentation of the imaging provided on March 4, 2020. Therefore, we decided that the Plan does not have to pay for the right knee x-ray examination provided on March 4, 2020.