Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve continued use of a negative pressure wound therapy pump. 
 
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says that the 
records show no updated measurements. 
 
The Plan follows Medicare rules. Medicare rules say that negative pressure wound pumps 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 device. Our physician 
reviewer found that the enrollee has multiple pressure wounds. He has been receiving wound care. There are 
updated measurements from November 2020 in the records that demonstrate that not all the wounds are 
healing. The do show a change in the enrollee's wound dimensions. The continued use of the device medically 
is reasonable and necessary to treat the enrollee's condition. 
 
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 device have been met. Therefore, we decided that the Plan has to 
pre-approve continued use of a negative pressure wound therapy pump.  
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's needs can now be met in a lower level of care. 
 
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 the enrollee's condition does not 
meet Medicare criteria for 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 skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from March 21, 2020, to 
March 23, 2020. 
 
You asked the Plan to pay for the inpatient hospital care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says you did not meet medical criteria for inpatient health care. 
 
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must 
furnish to the intermediary or carrier sufficient information to determine whether payment is due and the 
amount of payment.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, there were no medical records provided in this case. 
Without the medical records, we cannot review to see if the services were urgent/emergent or medically 
necessary. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided 
from March 21, 2020, to March 23, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on October 11, 
2018. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the appeal received more than 365 past the denial date of claim. 
 
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 services was not filed until October 16, 2020. This means that more than 
one calendar year from the original claim submission had passed before a reconsideration was filed. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided to the enrollee on October 11, 
2018.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections (96413, J3380, J7050) provided 
August 18, 2020 to September 1, 2020. 
 
You asked the Plan to waive the coinsurance for the injections. You say that the coinsurance should be waived. 
The Plan denied your request. The Plan says the correct cost sharing was applied. 
 
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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B drugs 
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 coinsurance for injections (96413, J3380, 
J7050) provided August 18, 2020 to September 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone graft at time of implant placement (D6104) and 
guided tissue regeneration (D4266) provided on July 6, 2020. 
 
You asked the Plan to pay for the bone graft and guided tissue regeneration. You say that a bridge is your only 
and healthiest choice. The Plan denied your request. The Plan says these services are not covered under 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, 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 bone 
graft at time of implant placement (D6104) and guided tissue regeneration (D4266) provided on July 6, 2020.  
 
Your complaint about your disappointment with the Plan benefits is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist physician services provided on 
February 13, 2020 and April 16, 2020. 
 
You asked the Plan to waive the copayment for the specialist physician services. You say that $45 copayments 
are too much. The Plan denied your request. The Plan says you were charged the copayments 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 physician services for visits to specialists.  
 
You have been asked to pay a $45 copayment for the specialist physician services. The specialist physician 
services fall within the physician services for visits to specialists 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 specialist physician services provided on February 13, 2020 and April 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the Part B drug or the injection provided on 
August 18, 2020. 
 
You asked the Plan to waive the cost share for the Part B drug and the injection. You say that the provider did 
not mention the coinsurance for the medication prior to receiving the service. The Plan denied your request. 
The Plan says you have been charged the correct cost sharing 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 20% 
coinsurance for Medicare Part B prescription drugs and a $20 copayment per visit to a specialist.  
 
You have been asked to pay a total of $195.40 for the Part B drug and the injection. The Part B drug falls 
within the Medicare Part B prescription drugs benefit category. The injection falls within the Physician/ 
Practitioner services, including doctors office visits benefit category. See chart below. 
  
 
Date of Service Service Allowed Amount Copayment/Coinsurance Member 
Liability 
August 18, 2020 Part B medication $876.96 20% $175.40 
August 18, 2020 Injection $93 $20 $20 
Total    $195.40 
 
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 cost share for the Part B drug or the injection provided on August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the custom fabricated abutment (D6057). 
 
You asked the Plan to pre-approve the custom fabricated abutment. You say that this service is medically 
necessary. The Plan denied your request. The Plan says this service is not a covered procedure under your 
supplemental 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, 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 
custom fabricated abutment (D6057).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Proton Beam Radiation Therapy & Image Guided Radiation 
Therapy. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that that there are not sufficient medical studies to support that Proton 
Beam Therapy & Image-Guided Radiation Therapy is superior to other treatments for breast cancer and 
therefore, are considered not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 these services. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Case reviews for proton 
therapy for breast cancer are challenging since proton therapy will invariably reduce heart and lung exposure- 
but not always in a clinically meaningful way, and an IMRT plan can often be made to look better or worse 
depending on beam arrangement, planning parameters, etc. Nevertheless, it is apparent that the non-proton plan 
can be considered unacceptable and it is plausible that the proton plan would be markedly better. While proton 
therapy is not necessary for routine use in the post-mastectomy setting, this case is arguably exceptional due to 
the linear extent of the scar, relatively high cardiac exposure with non-proton based IMRT, and referral from a 
radiation oncologist to another. Our physician reviewer found that the enrollee's condition meets criteria for 
coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve Proton Beam Radiation Therapy & Image Guided Radiation Therapy.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair and accessories expandable 
controller (E2377)expandable harness (E2313) and electronic connection (E2311) 
 
You asked the Plan to pre-approve a group 2 power wheelchair and accessories the upgraded electronics. You 
say that all items are relevant and needed for the current state of the enrollee's deficits. Continued delay puts 
her at risk of injury due to falls and inability to relieve pressure to prevent skin breakdown. The Plan denied 
your request. The Plan says the enrollee does not have a medical need to control power options through the 
joystick. 
 
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 upgraded electronics. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not reveal that the enrollee needs an expandable controller to 
operate other types of proportional input devices, non-proportional input devices or to operate 3 or more 
powered seating actuators through the drive control. The documentation does not reveal the enrollee needs the 
expandable controller to operate a separate display, other electronic devices or for an attendant control. The 
enrollee has sufficient strength in the upper extremities and functional ability to operate any power options 
through their own individual switches. The expandable harness (E2313), the (E2311) electronic connection, 
and the (E2377) expandable controller are 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 upgraded electronics have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 2 power wheelchair and accessories expandable controller 
(E2377)expandable harness (E2313) and electronic connection (E2311)
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 60MG/3Ml Durolane. 
 
You asked the Plan to pre-approve the Durolane. You say that you would like reconsideration because this drug 
is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy 
exception criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Durolane. Our reviewer says that 
the record does not show that the member has tried and failed a trial of Synvisc-One. Our physician reviewer 
found there is no indication that the Plan's required drug would likely be less effective and/or likely have 
adverse effects for the member. 
 
 
 
 
 
 
 
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 Durolane have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 60MG/3Ml Durolane.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 11, 2020, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. 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 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 medical services provided on March 11, 2020, 
by an out-of-network (OON) provider.
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 enrollee 
still requires acute hospital level of care services and is receiving appropriate care at the present acute care 
hospital. The enrollees medical needs are being met in the current acute setting. The enrollee does not require 
services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the occupational therapy visits provided 
from August 17, 2020, to August 21, 2020. 
 
You asked the Plan to waive the copayments for the occupational therapy visits. You say that you paid a $40 
copayment and the Plan paid a lesser amount. You say this seems the reverse of what should be paid. The Plan 
denied your request. The Plan says you have been charged the correct cost sharing 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 $40 
copayment per day for in-network Medicare-covered occupational therapy services.  
 
You have been asked to pay a $40 copayment for each of the occupational therapy visits. The occupational 
therapy visits fall 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 copayments for the occupational therapy visits provided from August 17, 2020, to August 21, 
2020.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after January 10, 
2021. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee still requires SNF services. The Plan 
denied your request. The Plan says that that there is no documentation of continued skilled medical needs. 
 
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will 
stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before 
the last covered day. This notice must include a description of the enrollee's right to an appeal.  
 
We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or 
more days before January 10, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is 
exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the 
Plan has to pre-approve continued skilled nursing facility (SNF) services after January 10, 2021.  
 
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 pay for the self-administered drug provided. 
 
You asked the Plan to pay for the self-administered drug. You say that you injured your finger and were given 
medication to help control the nausea caused by the pain. The Plan denied your request. The Plan says self-
administered drugs are not covered in an outpatient hospital setting. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drug 
provided.  
 
Benefits for the self-administered drug may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.