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

 
We decided that the Plan does not have to waive the copayment for the dermatology specialist visit you had on 
June 4, 2020. 
 
You asked the Plan to waive the copayment for the dermatology specialist visit. You say that this copayment 
should be waived because you received a card from the Plan stating that due to COVID-19, all out-of-pockets 
costs are waived. The Plan denied your request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 
copayment for specialist visits.  
 
You have been asked to pay a $45 copayment for the dermatology specialist visit. The card that you received 
from the Plan indicating that certain copayments are being waived explicitly states that this copayment waiver 
applies only to primary care visits, outpatient behavioral health visits, and telehealth visits.  This waiver does 
not apply to specialist visits. 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 the dermatology specialist 
visit you had on June 4, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional home health skilled nursing visits. 
 
You asked the Plan to pre-approve 6 home health skilled nursing visits. You say that the additional home health 
skilled nursing visits are medically necessary. The Plan denied your request. The Plan says the records do not 
support the medical necessity for additional home health skilled nursing visits. 
 
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 6 home health skilled nursing visits. 
Our reviewer says that the documentation does not support that the enrollee requires skilled nursing services or 
skilled rehab services to provide treatment that is medically necessary. Our physician reviewer found the 
enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services 
 
 
in order to improve the enrollees condition, perform a maintenance program to maintain the patients 
condition and/or prevent deterioration.  The enrollee has been medically stable without any recent exacerbation 
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 6 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 6 additional home health skilled nursing visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271). 
 
You asked the Plan to pre-approve Keytruda. You say that this will improve the enrollee's quality of life. The 
Plan denied your request. The Plan says this is not recommended for the enrollee's condition. 
 
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 Keytruda. Our reviewer says that the 
criteria for coverage of Keytruda have not been met. Our physician reviewer found the FDA approval of 
Keytruda based on first-line treatment of unresectable or metastatic MSI-H of dMMR colorectal cancer; 
treatment of unresectable or metastatic, MSI-H or mismatch repair deficient colorectal cancer in adult and 
pediatric patients that have progressed following treatment with a fluoropyrimidine, oxaliplatin, and irinotecan. 
The enrollee has not had MSI or MMR testing. 
 
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 (J9271).
Appeal type: Drugs
Decision: Unfavorable

We decided thatthe Plan does not have to pre-approvechemotherapy drugs.You asked the Plan to pre-approvethe requested services. You say that the enrollee needs life-saving chemotherapy medication.The Plan denied your request. The Plan says the costs in a clinical trial are covered by Original Medicare.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve services as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials.Therefore, we decided that the Plan does not have to pre-approvechemotherapy drugs.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical condition does not require further 
hospital care. 
 
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. The enrollee 
does not require services at a LTACH that would not be provided at a skilled nursing facility. She requires 
assistance with mobility, taking medications, and feeding tube management. Our physician reviewer found that 
the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to LTACH. 
 
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. The patient 
appears to be improving overall, but requires an additional short term stay in the acute care hospital (less than 
25 days) to stabilize her blood count, which can be safely completed at the current facility. The patient does not 
require services at the LTACH that are not already available at the current facility. Our physician reviewer 
found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, wheelchair harness upgrade, 
and electric connection between the wheelchair controller and two or more power seating system motors. 
 
You asked the Plan to pre-approve an expandable controller, wheelchair harness upgrade, and electric 
connection between the wheelchair controller and two or more power seating system motors. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items 
are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for 
certain indications. 
 
We looked at the file and Medicare rules. Review of the file shows that the approved power options come with 
their own switches. The documentation shows that the enrollee's upper limb strength and function are adequate 
to be able to control the power options using their own switches which are included in the allowance of these 
power options. Based on this information, we decided that Medicare rules for coverage of an expandable 
controller, wheelchair harness upgrade, and electric connection between the wheelchair controller and two or 
more power seating system motors have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an expandable controller, wheelchair harness upgrade, and electric connection between the 
wheelchair controller and two or more power seating system motors.
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 SNF admission. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the requested admission is not medically necessary. 
 
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 admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. 
The enrollee had stable vital signs. The enrollee required minimal to moderate assistance with functional 
mobility including walking to 5 feet with a rolling walker. The documentation does not support that the 
enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified 
therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation 
does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical 
matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF 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 SNF 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prefabricated post and core for teeth #10 and 11. 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says the services 
are 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. 
 
Although the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
prefabricated post and core for teeth #10 and 11.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve lower partial dentures. 
 
You asked the Plan to pre-approve lower partial dentures. The Plan denied your request. The Plan says that the 
enrollee is not missing enough teeth to keep them from chewing correctly. 
 
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 lower partial 
dentures 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 lower partial dentures. Our physician 
reviewer found that teeth #'s 19 and 30 are to be extracted. It is medically reasonable and necessary to replace 
these teeth with a mandibular removable partial denture to maintain good bilateral masticatory function, and to 
prevent tipping and extrusion of teeth into the edentulous spaces. Therefore, the requested denture is medically 
reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of lower partial dentures have been met. Therefore, we decided that the Plan has to 
pre-approve lower partial dentures.  
 
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 patient assessment provided on August 18, 2017, limited 
oral evaluation provided on October 11, 2017 and cone beam CT capture provided on February 16, 2018.  
 
You asked the Plan to pay for the patient assessment, limited oral evaluation and cone beam CT capture. You 
say that the Plan is failing to abide by the terms of your benefits. You say that the provider performed the work 
because other providers could not. The Plan denied your request. The Plan says the claim was not received 
within 12 months. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the patient assessment, limited oral evaluation and cone beam CT capture 
was not filed until December 27, 2019. This means that more than one calendar year from the date of service 
had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the patient 
assessment provided on August 18, 2017, limited oral evaluation provided on October 11, 2017 and cone beam 
CT capture provided on February 16, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care, per day (99232) rendered by the 
out of network (OON) provider from February 19, 2020, through February 25, 2020. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 the subsequent hospital care, per day (99232) rendered by the out of network (OON) 
provider from February 19, 2020, through February 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET scan with concurrently acquired CT, whole body 
for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the guidelines do not support PET imaging for initial staging of prostate cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found this review relates to a 
request for a PET/CT scan as part of initial staging evaluation for a 61 year old man with newly diagnosed 
prostate cancer with Gleason's 4+4 on all 12 biopsy cores. The prescriber states he has high risk disease. A CT 
of the pelvis has also been ordered. Per the NCCN Guidelines Version 2.2020 Prostate Cancer page PROS-2, 
there is no category of initial risk for which a PET scan is indicated as part of the initial staging work-up. The 
prescriber has not indicated how the results of a PET scan will be used to determine whether or not the enrollee 
is an appropriate candidate for an invasive diagnostic or therapeutic procedure; or how it will determine the 
optimal anatomic location for an invasive procedure; or to determine the anatomic extent of tumor when the 
recommended anti-tumor treatment reasonably depends on the extent of the tumor. Therefore, the enrollee does 
not have an indication for PET scan at this time and a PET scan is not 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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve PET scan with concurrently acquired CT, whole body for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the in network rate for the immediate dentures and 8 extractions 
provided on February 12, 2020 by the out of network dental provider. 
 
You asked the Plan to pay the in network rate for the dental services. You say that there are no in network 
providers for denture services. You say that an in network dentist referred you to this dentist for the extractions 
and dentures. You also say that the services should be paid at the in network rate since your in network dentist 
referred you for the services and due to the inadequate amount in network providers. The Plan denied your 
request. The Plan says dental services that you receive out of network are paid at 50% of the allowed amount. 
The Plan says that there is no referring provider listed. The Plan also says that the services could be provided in 
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 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay the in 
network rate for the immediate dentures and 8 extractions provided on February 12, 2020 by the out of network 
dental provider.
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 additional care required can be provided in the home or basic care 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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs. You do not require skilled nursing or therapy services on a daily basis. You do not not meet 
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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)