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

 
We decided that the Plan does not have to pre-approve an interspinous spacer. 
 
You asked the Plan to pre-approve the spacer. You say that you would like reconsideration because this device 
will provide significant clinical and quality of life benefits. The Plan denied your request. The Plan says the 
requested device is considered experimental. 
 
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 spacer. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found this device remains experimental and more research is needed to show its safety and efficacy. 
 
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 spacer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve an interspinous spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this service is covered under the plan's benefit package, but exceeds the maximum count 
allowed per pay period. 
 
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. The Plan covers the services 
when the services are medically necessary and reasonable.  
 
You last received dentures less than five years go on 10/11/18. Based on this information, we decided that the 
Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a complete maxillary and mandibular denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator. 
 
You asked the Plan to pre-approve 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 Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have an oxygen home fill station. This item serves the same purpose as the requested 
portable oxygen concentrator. Therefore, we decided that the Plan does not have to pre-approve a portable 
oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve the monitor. You say that you are aware of the OTC benefit, but you want 
this covered under Part B. The Plan denied your request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildups, including any pins when required 
(D2950) for tooth #'s 9, 30, and 31 and two crowns (D2751 x2). 
 
You asked the Plan to pre-approve the core buildups. You say that there is urgent need for the core buildups. 
The Plan denied your request. The Plan says this service is not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 core 
buildups, including any pins when required (D2950) for tooth #'s 9, 30, and 31 and two crowns (D2751 x2).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9612), consultation 
(D9310), and removal of reaction producing foreign bodies (D7540). 
 
You asked the Plan to pre-approve the therapeutic parenteral drugs, consultation, and removal of reaction 
producing foreign bodies. You say that you are in a lot of pain. The Plan denied your request. The Plan says 
these services are not covered under your benefit package. 
 
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 
therapeutic parenteral drugs (D9612), consultation (D9310), and removal of reaction producing foreign bodies 
(D7540).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a biopsy provided on February 20, 2020. 
 
You asked the Plan to waive the copayment for a biopsy. You say that you are not able to afford your medical 
expenses. The Plan denied your request. The Plan says the copayment you are being charged is correct. 
 
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 $250 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.  
 
You have been asked to pay a $250 copayment for a biopsy. Biopsies fall within the Outpatient Surgery and 
Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 a biopsy provided on February 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 drug. Our reviewer says that the 
requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not 
tried and failed zoledronic acid. There is no documentation provided indicating that the the plan's required drug 
would likely be less effective and/or have adverse effects for the enrollee. In addition, the enrollee does not 
have a history of an osteoporotic fracture. The requested Prolia is 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 drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia for the enrollee.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve PET imaging with concurrently acquired CT for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the clinical information provided does not include results of a biopsy to confirm the 
diagnosis of 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 imaging. Our reviewer says that the 
requested imaging is medically reasonable and necessary. Our physician reviewer found the enrollee has a past 
history of poorly differentiated squamous cell cancer of the base of the tongue with positive margins. The last 
PET/CT was 3/12/19 which revealed asymmetric uptake at the base of the tongue on the right.  PET/CT has 
been requested to differentiate post therapy fibrotic changes from tumor recurrence. This test is the best way to 
evaluate an anatomic space, base of tongue, since this area is hard to evaluate accurately with CT especially 
given the history of surgery, chemo and radiation therapy. There has been a biopsy confirmed aggressive  
cancer with positive margins in the past and the patient presents with symptoms which could indicate tumor 
recurrence. 
 
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 imaging have been met. Therefore, we decided that the Plan has to pre-
approve PET imaging with concurrently acquired CT for the enrollee.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on March 20, 2020. 
 
You asked the Plan to waive the copayment for an MRI. You say that you only paid $50 in the past and 
disagree with the increase in charges. The Plan denied your request. The Plan says the claims were processed 
correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $150 
copayment for each diagnostic radiology service.  
 
You have been asked to pay a $150 copayment for an MRI. An MRI falls within the outpatient diagnostic tests 
and therapeutic services and supplies 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 a 
magnetic resonance imaging (MRI) provided on March 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical supplies provided on March 26, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration 
because this equipment is required in the event of power outages at home. The Plan denied your request. The 
Plan says this provider does not participate with Medicare or the Plan and there are numerous in-network 
providers within your zip code. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that durable medical equipment is not covered out-of-network. 
 
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 supplies provided on March 26, 2020 
by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on December 13, 2019. 
 
You asked the Plan to pay for the physician's services. 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 
physicians services. We found no exception that would require the Plan to pay for these services. Therefore, 
we decided that the Plan does not have to pay for physician's services provided on December 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient mental health services provided from March 7, 
2020, to March 17, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the inpatient care was 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 services. Our reviewer says that the 
requested inpatient mental health services are not medically reasonable and necessary. Our physician reviewer 
found that the enrollee did not appear to require inpatient mental health treatment as he was not a danger to 
himself or others and was cooperative and compliant. It did not appear that active treatment was taking place. It 
did not appear that the services were reasonably expected to improve the patients condition or for the purpose 
of diagnosis. 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient mental health services provided from March 7, 2020, to March 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on May 14, 2020. 
 
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you understand the 
frequency limitation, but this was an emergency because you needed these teeth extracted. The Plan denied 
your request. The Plan says this service exceeds the frequency limitation in the benefit plan. 
 
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, problem focused limited oral 
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem 
focused limited oral evaluation on May 20, 2020 and your problem focused limited oral evaluation (D0140) 
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused 
limited oral evaluation (D0140) provided on May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for observation care (99219) provided on March 31, 2019. 
 
You asked the Plan to pay for observation care. You say that you did not receive the information necessary to 
submit this claim on time. The Plan denied your request. The Plan says claims must be submitted within a year 
of the service. 
 
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 observation care was not filed until April 28, 2020. 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 observation care (99219) provided on March 31, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on review of the medical records, you do not meet the CMS coverage criteria 
for an IRF admission based on lack of medical intensity and nursing needs. There is no evidence of medical 
issues that require monitoring by an inpatient rehab physician three times a week after a hip fracture and 
surgery. The documentation does not support that there is a need for an intensive therapy program with 3 hours 
a day and an interdisciplinary approach to rehab care. You will benefit from continuing physical therapy (PT) 
and occupational therapy (OT) and still need therapies but not in an IRF. You do not meet the CMS coverage 
criteria for an IRF admission. Your rehab needs can be met in an alternate, less intense setting such as in an 
skilled nursing facility (SNF). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve the OON inpatient psychiatric care. You say that the enrollee has been 
court-ordered to this facility for forensic evaluation and could not be managed at a lower level of care due to 
her condition. This should be approved by the plan. The Plan denied your request. The Plan says there are no 
medical reasons noted that the enrollee is unable to be treated by a network psychiatric provider. While the 
court order requires care from the OON facility, this is not a Medicare-allowed exception to the network 
restrictions of her plan. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
inpatient psychiatric care to be provided by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure (15830) to be provided by an out of 
network (OON) provider. 
 
You asked the Plan to pre-approve a surgical procedure. You say that the service is necessary. The Plan denied 
your request. The Plan says there are in-network providers that are able to provide this service. Therefore, 
coverage criteria has not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a surgical procedure (15830) to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Inflectra. 
 
You asked the Plan to pre-approve Inflectra. 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 must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare 
coverage criteria have been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Inflectra have not been met. Specifically, medical records were not provided. Without this 
documentation, medical necessity is not able to be established. Therefore, we decided that the Plan does not 
have to pre-approve Inflectra.