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

 
We decided that the Plan does not have to pre-approve a dose of 375mg of Xolair (Omalizumab injections) 
every 14 days. 
 
You asked the Plan to pre-approve Omalizumab. You say that you are on 3 different oral inhalers, and feel that 
injections would be less dangerous. The Plan denied your request. The Plan says Xolair is not medically 
reasonable and necessary. 
 
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 Omalizumab. Our reviewer says that 
the documentation does not support that the requested drug is currently medically necessary and reasonable. 
Our physician reviewer found the documentation does not support that the injections are safe and effective for 
you. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Omalizumab have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a dose of 375mg of Xolair (Omalizumab injections) every 14 days.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the breasts for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no contraindication to undergoing the standard mammogram with the presence 
of breast implants. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found there are no physical or 
imaging findings to imply implant rupture. In fact, physical exam is negative. There is no genetic 
predisposition to breast cancer described and no mammographic abnormality such as equivocal finding or 
extremely dense tissue to indicate medical necessity for breast MRI.  Guidelines from ACR describe 
mammography as the first screening exam of choice in all patients even those with augmentation implants. 
Medical necessity for breast MRI has not been established 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the breasts for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cast metal frame partial lower 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 the requested service would not be a covered benefit based on policy guidelines and plan 
benefit coverage. 
 
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 the services 
when the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found you have been 
approved for an upper partial denture.  When the upper partial denture is worn, there is contact on teeth #s 2/31, 
5/28, 12/21, 13/20 and 15/18.  The plan limits partial dentures to situations where there are less than eight 
points of posterior contact. With the upper partial in place, there would be at least 10 posterior contact points 
present. As there are sufficient posterior contacts available when the upper appliance is worn, the criteria for a 
lower partial denture is not met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a cast metal frame partial lower denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance provided on May 15, 2020. 
 
You asked the Plan to pay for periodontal maintenance. You say that $15 of your dental reimbursement was not 
covered. You say that this should be covered under preventive care. The Plan denied your request. The Plan 
says the services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under the preventive benefit. Therefore, we decided that the Plan does not have to pay for 
periodontal maintenance provided on May 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 25, 
2020. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
that the Plan requires utilization of network providers, when possible and available, and requires authorization 
for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 
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 subsequent nursing facility care provided on January 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to preapprove a pneumatic compression device (E0651). 
 
You asked the Plan to preapprove a pneumatic compression device. You say that the claim should be paid. The 
Plan denied your request. The Plan says no documentation of failed 4-week trial of conservative treatment 
consisting of regular and complaint use of an appropriate compression bandage system or compression garment 
to provide adequate graduated compression. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of 
lymphedema after a documented four-week trial of conservative therapy including compression garments, 
regular exercise, and elevation.  
 
There's no documentation of failed 4-week trial of conservative treatment consisting of regular and complaint 
use of an appropriate compression bandage system or compression garment to provide adequate graduated 
compression. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device 
(E0651).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with 
suspension sleeve (L1851, L2397) provided to the enrollee on December 19, 2019. 
 
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your 
request. The Plan says the documentation does not meet Medicare coverage criteria. 
 
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 proof of delivery for the supplies provided in this case. The proof of 
delivery does not have a signature from the enrollee to confirm that the enrollee received the supplies. 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 for a lumbar-sacral orthosis (L0650) and a knee 
orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on December 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing 
facility, home with home health and home physical therapy, or home with outpatient therapy. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the enrollee's functional status requires  or can tolerate an intensive rehabilitation therapy program 
provided in an IRF. 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and an abutment 
supported porcelain fused to metal crown (D6059). 
 
You asked the Plan to pre-approve the custom fabricated abutment and abutment supported porcelain fused to 
metal crown. You say that you need these services, but you cannot pay for them. 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 pre-approve a 
custom fabricated abutment (D6057) and an abutment supported porcelain fused to metal crown (D6059).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that the stockings are required for an 
operation that is coming and your physician says you need them. The Plan denied your request. The Plan says 
these stockings are only covered when there is a qualifying wound. 
 
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530 
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that 
compression bandages and gradient compression wraps are covered only when they are used as dressings over 
a qualifying wound. 
 
The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you 
do not have a medical condition for which compression stockings can be covered or paid for by Medicare. 
Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code 
A6530.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says the services can be safely received in other settings, for example: skilled nursing facility. 
 
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 the enrollee does not require the intensity of services provided at an IRF.  
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular 
physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR). 
 
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive your copayment for the skilled nursing facility (SNF) services 
you received from February 3, 2020 through February 29, 2020. 
 
You asked the Plan to waive your copayment for the SNF services. You say that you don't think you should 
have to pay this copayment because you got two infections while you were at the SNF. You said it wasn't your 
fault you got sick. 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 $20 
copayment for days 1-20, a $60 copayment per day for days 21-44, and a $0 copayment per day for days 45-
100 for skilled nursing facility services.  
 
You were in the SNF for a total of 27 days.  You were charged a $20 copayment for days 1-20 (for a total of 
$400), and a $60 copayment per day for the remaining 7 days (for a total of $420). The total copayment due for 
the entire SNF stay is $820, which is exactly the amount the Plan is charging you. This means that you have 
been asked to pay the correct amount based on your contract with the Plan. This amount applies regardless of 
the reason for the length of your stay. 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 your copayment for the skilled 
nursing facility (SNF) services you received from February 3, 2020 through February 29, 2020.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve the MRI, spinal canal and contents, lumbar; without contrast 
material (CPT Code 72148) and the MRI, spinal canal and contents, thoracic; without contrast material (CPT 
Code 72146). 
 
You asked the Plan to pre-approve the MRI's. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI's. Our physician reviewer 
found the patient has persistent pain with no improvement despite analgesia (NSAIDS) and brace. The patient 
has had negative plain films. The MRI is 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 MRI's have been met. Therefore, we decided that the Plan has to pre-
approve the MRI, spinal canal and contents, lumbar; without contrast material (CPT Code 72148) and the MRI, 
spinal canal and contents, thoracic; without contrast material (CPT Code 72146).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 10, 2019. 
 
You asked the Plan to pay for the services provided. You say that the services billed are only for the 
professional fee. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the pathology services are not supported in the medical record for the date of service at issue. 
Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on October 10, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Buprenorphine patches. 
 
You asked the Plan to pre-approve the Buprenorphine patches. You say that you have been placed in the 
hospital for significantly overtaking Tylenol, and the Buprenorphine patch is less likely to be abused. The Plan 
denied your request. The Plan says this drug is not covered for your condition by Medicare Part B. 
 
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 pre-approve Buprenorphine patches.  
 
Benefits for Buprenorphine patches may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital discharge day management; more than 30 minutes 
(CPT Code 99239) provided on February 27, 2019. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
Current Procedural Terminology (CPT) code 99239 -GC (1 Units) remains not supported. The submitted 
discharge summary does not support hospital discharge day management of more than 30 minutes was 
performed. A documented duration of time of 31 minutes or more is required to support this code. Therefore, 
the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for 
additional information. We have insufficient documentation to corroborate the services so we can confirm 
Medicare coverage has been met. 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 hospital discharge 
day management; more than 30 minutes (CPT Code 99239) provided on February 27, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for osseous surgery (D4261) provided on April 6, 2020. 
 
You asked the Plan to pay for osseous surgery (D4261). You say that the best care plan was to cut the gum to 
release the infection. You say that this was necessary and should be covered. The Plan denied your request. The 
Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 osseous 
surgery (D4261) provided on April 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the neck and spine. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found the physician's notes 
are handwritten and very brief and difficult to read.  However, there is no documented red flag to mandate 
immediate imaging with MRI. There is no reflex abnormality, no EMG or nerve conduction study and no plan 
for PT and conservative management. Absent these factors in the absence of red flags medical necessity for 
MRI of the cervical and thoracic spine has not been established. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the neck and spine.