Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 24, 
2020, to August 22, 2020. 
 
You asked the Plan to pay for the SNF care. You say that you would like this claim reprocessed and approved 
for payment. The Plan denied your request. The Plan says rules for SNF care were not met. 
 
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 pay for the SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing 
service needs and no identifiable skilled therapy service needs. In addition, the beneficiary does not require 
skilled nursing or therapy services on a daily basis and does 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from July 24, 2020, to August 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve neurostimulators (63650). 
 
You asked the Plan to pre-approve neurostimulators. You say that the services are necessary. The Plan denied 
your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that dorsal column stimulators may be covered as 
therapies for the relief of chronic intractable pain under specific circumstances. 
 
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 neurostimulators. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee does not have an 
evidence based indication for a spinal cord stimulation (SCS) trial. The request is 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 neurostimulators have not been met. Therefore, we decided that the Plan does 
not have to pre-approve neurostimulators (63650).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (CPT Code 93925) and complete bilateral noninvasive physiologic studies of upper or lower extremity arteries (93923).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the doctor ordered an imaging test for the enrollee's legs (duplex scan) and this test was ordered to check the blood flow in arteries in their pelvis before a kidney transplant. The Plan states the enrollee had a scan on January 26, 2021, (computed tomography angiogram) that showed normal blood flow in these vessels. Therefore, this test requested is not needed. This test is not medically necessary.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The enrollee had a scan in January of this year. That was normal. As per the LCD, "there must be a high index of suspicion that the pain is caused by a vascular disorder, such as mesentery ischemia. And Noninvasive vascular studies are medically necessary only if the outcome will potentially impact the clinical course of the patient." This appears to be screening prior to surgery, which is not covered. Therefore, we decided that the Plan does not have to pre-approve duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (CPT Code 93925) and complete bilateral noninvasive physiologic studies of upper or lower extremity arteries (93923).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy. 
 
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested proton beam 
radiation therapy is medically necessary. The Plan denied your request. The Plan says the requested proton 
beam radiation therapy is not medically necessary. 
 
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 proton beam radiation therapy. Our 
reviewer says that the requested proton beam radiation therapy is not medically necessary. Our physician 
reviewer found this enrollee's tumor is very peripheral such that retreating it would not expose the critical 
central tissues (heart, major vessels or bronchi) to appreciable doses; retreating central tumor can warrant 
consideration of proton reirradiation given the risks to those tissues. Retreating a peripheral lung tumor with 
SBRT is certainly feasible, though treating it with conventional fractionation would be acceptable in an effort 
to treat in a different manner than the original treatment. The critical tissues that would be encompassed in the 
radiation field include the right lung and chest wall.  It is not evident that proton therapy would reduce 
exposure to either of these tissues (the target is right up against the chest wall). Sparing the lung is arguably 
less critical as the exposure would be relatively low for a peripheral lung tumor, and data from MDACC and 
other institutions show that reirradiated lung is less susceptible to toxicity as the lung injury has already 
occurred. 
  
In summary, there is no evidence that proton therapy is needed over other accepted treatments.  There is no 
plausible reason that proton therapy would be more beneficial than standard therapy for this particular enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nitrous oxide services rendered on July 17, 2020. 
 
You asked the Plan to pay for these services. You say that you refused the 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. 
 
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 
nitrous oxide services rendered on July 17, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care provided to the enrollee from February 3, 
2021, forward. 
 
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer 
found based on the medical records provided there is no documentation that the enrollee requires skilled 
nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse is not 
required to safely and effectively provide medically necessary and reasonable treatment. This enrollee does 
require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist is 
required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services 
are not required. This enrollee does not require the services on an inpatient basis, only in a skilled nursing 
facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 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 care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care provided to the enrollee from February 3, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and removal of 
residual tooth roots (D7250) of tooth #20 provided on September 30, 2020, and October 7, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation and removal of residual tooth roots. You say 
that you had tooth #20 removed a few years ago, but a root tip was left behind that you needed to have 
removed. The Plan denied your request. The Plan says these services exceed the frequency limitations 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, comprehensive oral evaluation 
(D0150) is limited to one procedure every three plan years. The record shows that you received a 
comprehensive oral evaluation (D0150) on August 22, 2018, and your comprehensive oral evaluation (D0150) 
benefit has been exhausted. The Plan contract also says that you are limited to one of codes D7111, D7140, 
D7210, or D7250 per tooth per lifetime of the member. The record shows that you received a surgical 
extraction (D7210) of tooth #20 on February 23, 2018, and your removal of residual tooth roots (D7250) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive 
oral evaluation (D0150) and removal of residual tooth roots (D7250) of tooth #20 provided on September 30, 
2020, and October 7, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoral periapical X-rays (D0220, D0230) received on October 8, 2020.
You asked the Plan to pay for intraoral periapical X-rays. You say that this was your first time using your dental plan for a routine teeth cleaning and you were unaware that the Plan does not cover what you believe to be normal coverage. The Plan denied your request. The Plan says the requested items/services are not covered under your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 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 intraoral periapical X-rays (D0220, D0230) received on October 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on July 20, 2020.You asked the Plan to pay for the laboratory 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 theplan.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 Plandid not pre-approve the laboratory 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 laboratory services provided on July 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve topical application of fluoride varnish (D1206), 
complete maxillary denture (D5110), immediate maxillary denture (D5130), and mandibular partial denture 
(D5214). 
 
You asked the Plan to pre-approve the topical application of fluoride varnish, complete maxillary denture, 
immediate maxillary denture, and mandibular partial denture.. You say that the enrollee needs dentures after 
the removal of their teeth in order to be able to eat and adjust to normal life. The Plan denied your request. The 
Plan says these services are not covered under the enrollee's 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 pre-approve 
topical application of fluoride varnish (D1206), complete maxillary denture (D5110), immediate maxillary 
denture (D5130), and mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for DME provided on December 31, 2019. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says non-emergent, non-
urgent services with out-of-network providers require 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 did not pre-approve the 
DME. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to pay for DME provided on December 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lead wires rendered on September 11, 2020. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that replacement of lead wires (A4557) more often than 
every 12 months would rarely be reasonable and necessary. 
 
We looked at the file and Medicare rules. The file shows that the TENS device was rendered on August 11, 
2020. Replacement lead wires more often than every 12 months is not necessary. Therefore, we decided that 
the Plan does not have to pay for the lead wires rendered on September 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fordiabetic shoes (A5501) and inserts (A5513) provided on March 9, 2020.You asked the Plan to pay fordiabetic shoes and inserts. You say that these items were medically necessary.The Plan denied your request. The Plan says there is not a physician order or proof of delivery for these items.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid physician order and proof of delivery for the supplies provided in this case. These documents were not included in the submitted medical records. The record shows that the Plan made several attempts to obtain the necessary documentation without success.Therefore, we decided that the Plan does not have to pay fordiabetic shoes (A5501) and inserts (A5513) provided on March 9, 2020
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve stereotactic body radiation therapy (SBRT) with image guided
radiation therapy (IGRT).
You asked the Plan to pre-approve SBRT with IGRT. You say that the requested SBRT with IGRT is
medically necessary. The Plan denied your request. The Plan says that the requested SBRT with IGRT is 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 SBRT with IGRT. Our reviewer says
that the requested SBRT with IGRT is medically necessary. Our physician reviewer found for this enrollee, the
plan is to treat 2 lung lesions. The HPI is lacking details of prior cancer stage and prior treatment (other than
SBRT to spine metastases and immunotherapy). So it is unclear if she previously had widespread disease, with
2 sites of growth or "metachronous oligometastases" which would be differentiated from oligoprogression in
which a patient with widespread metastases experiences progression of one or a few sites. However, some term
"metachronous oligometastases" as "oligoprogression". One can argue for the need of SBRT in either case
(metachronous oligometastases or oligoprogression) though SBRT for patient with widespread metastases is
more controversial (even is a patient with 1-2 sites of metastatic disease). So it seems acceptable and to
consider SBRT or hypofractionated (6-10 treatments) stereotactic radiotherapy for patients with metastatic sites
that are generally accepted as safe to treat per NCCN guidelines.
As such a treatment is in accordance with NCCN guidelines, it would follow that is within accepted standards
of medical practice.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SBRT with IGRT have been met. Therefore, we decided that the Plan has to
pre-approve stereotactic body radiation therapy (SBRT) with image guided radiation therapy (IGRT).
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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to hold the enrollee harmless forthe inpatient hospital services received from September 2, 2020 to September 3, 2020.You asked the Plan to hold the enrollee harmless forthe inpatient hospital services minus any cost share requirement. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the services received were not medically necessary.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. The plan follows these rules.We decided that this case also meets prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. The enrollee was brought to the closest Emergency Department. Whether or not the enrollee was admitted to inpatient status was not the enrollee's decision.In addition, the enrollee was referred for the inpatient hospital services by a contract provider. The file does not show that the plan provided notice that the inpatient hospital services would not be covered. Under Medicare rules, this means the inpatient hospital services is considered approved by the plan.Therefore, we decided that the Plan has to hold the enrollee harmless forthe inpatient hospital services received from September 2, 2020 to September 3, 2020 minus any cost share requirement.
If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve D-PACE (dexamethasone, cisplatin, doxorubicin, 
cyclophosphamide, etoposide) for the enrollee. 
 
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your 
request. The Plan says criteria is not met and this is considered experimental. 
 
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 the drugs. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the combination of 
cyclophosphamide, pomalidomide, and dexamethasone is not a standard treatment for maintenance therapy for 
multiple myeloma after transplant. Use in not favored by the NCCN Guidelines for maintenance therapy but for 
relapse/recurrence and this patient does not have indications of this. The service is 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 drugs have not been met. Therefore, we decided that the Plan does not have 
to pre-approve D-PACE (dexamethasone, cisplatin, doxorubicin, cyclophosphamide, etoposide) for the 
enrollee.