Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. 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 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. Our 
physician reviewer found based on the notes, the enrollee appears to be more stable but requires only a short 
extension of acute care services which can be safely administered at the current facility. The enrollee does not 
require services at the LTACH that are not already available at the current facility. There are no services at the 
current facility that the enrollee requires that are not already available and covered at the current facility. 
Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to 
a lower level of care may be considered when treatment has completed. 
 
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 LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a HIFU (CPT Code C9747). 
 
You asked the Plan to pre-approve the HIFU. You say that the service is necessary. The Plan denied your 
request. The Plan says the enrollee's prostate cancer is not a recurrence and they have not been previously 
treated with radiation therapy. The Plan states that the documentation submitted provides no additional 
information that justifies this request. 
 
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 HIFU. Our physician reviewer 
found per coverage criteria HIFU is indicated for recurrent prostate cancer treated with prior radiation therapy. 
This patient has not received any prior therapy for his prostate cancer. 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 HIFU have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a HIFU (CPT Code C9747).
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a maxillary partial denture - cast metal framework (D5213). 
 
You asked the Plan to pre-approve a maxillary partial denture. You say that the service is medically necessary. 
The Plan denied your request. The Plan says that the service is not medically necessary. 
 
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 maxillary 
partial denture 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 maxillary partial denture. Our reviewer 
says that the service is medically necessary. Our physician reviewer found that the partial denture is medically 
reasonable and necessary to restore good bilateral masticatory function and to prevent the drifting and extrusion 
of the adjacent and opposing teeth. 
 
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 maxillary partial denture have been met. Specifically, the service is medically 
necessary and there is no indication you have exhausted your supplemental benefits for this service. Therefore, 
we decided that the Plan has to pre-approve a maxillary partial denture - cast metal framework (D5213).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive exam with dental code D0150 provided 
on August 18, 2020. 
 
You asked the Plan to pay for dental code D0150. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the service is a covered benefit; however, you 
have exceeded the frequency limits set in the subscriber agreement. The Plan says that dental code D0150 has a 
frequency limit of one procedure every three plan years. The Plan says that you received this same service on 
February 18, 2018, which is less than three plan years ago. 
 
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. 
 
We looked at the file, the Plans contract and Medicare rules. The file shows that you received a comprehensive 
dental exam with dental code D0150 on August 18, 2020. Your contract with the Plan clearly states this service 
has a frequency limit of one procedure every three years. The file shows you received this service on February 
18, 2018, which is less than three years ago. Therefore, we decided that the Plan does not have to pay for the 
comprehensive exam with dental code D0150 provided on August 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ten extractions and maxillary interim complete denture 
provided from July 15, 2020, to August 10, 2020. 
 
You asked the Plan to pay for the extractions and maxillary interim complete denture. You say that you needed 
to have teeth removed. The Plan denied your request. The Plan says these services are purely dental in nature, 
and are unrelated to the limited clinical indications. The Plan also says that these services are not eligible for 
coverage under the medical benefit. 
 
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 Plan offers a $250 allowance every 
year for Non-Medicare covered preventive and comprehensive dental services combined. The contract says that 
you are responsible for any amount above the dental coverage limit. The record shows that you met the annual 
maximum benefit on July 15, 2020, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the ten extractions and maxillary interim complete denture 
provided from July 15, 2020, to August 10, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trastuzumab injections for 6 visits. 
 
You asked the Plan to pre-approve the trastuzumab injections. You say that the injections are medically 
necessary. The Plan denied your request. The Plan says the enrollee has not trialed and failed the plan-preferred 
medications. The Plan also says that the requested drug is not medically reasonable or 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 trastuzumab injections. Our 
reviewer says that the trastuzumab injections are not medically necessary. Our physician reviewer found the 
documentation provided does not show that the enrollee trialed and failed the preferred medications, 
TrazimeraTM and KanjintiTM. Therefore, the reviewer found that the requested injection 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 trastuzumab injections have not been met. Additionally, the record shows 
that the provider indicated that the plan-preferred medications would be ordered for the enrollee in place of the 
trastuzumab. Therefore, we decided that the Plan does not have to pre-approve trastuzumab injections for 6 
visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 medically necessary. Our physician reviewer found the enrollee was 
admitted to the hospital with respiratory failure related to empyema and septic shock, requiring intubation, 
chest tube, and tracheostomy. He does not require services at the LTACH that are not already available at the 
current facility. There are no services at the LTACH that the enrollee requires that are not already available and 
covered at the current facility. The LTACH services 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 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.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI received on October 3, 2020. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were not informed about the 
copayment for these services. The Plan denied your request. The Plan says the claim has been processed 
correctly per your plan benefits. 
 
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 $200 
copayment for outpatient diagnostic tests.  
 
Your copayment requirement for an MRI scan is $200. However, the allowed amount for this service was 
$197.29. Since this is less than your $200 copayment requirement, you were charged the lesser amount. 
 
You have been asked to pay a $197.29 copayment for the MRI. The MRI falls within the outpatient diagnostic 
tests 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 the MRI received on October 3, 
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a stair glide. 
 
You asked the Plan to pay for a stair glide. You say that you are legally blind, severely hard of hearing, and a 
polio survivor. You say that, as a polio survivor, you have been diagnosed with post polio syndrome and 
depend on a walker to get around. You say that you can no longer climb the stairs to enter your home from 
outside or reach your upstairs bedroom. You say that, at the time you purchased the stair lift, you didn't know 
that there was coverage through the Plan. You say that you have a limited income with social security. The 
Plan denied your request. The Plan says stairway elevators are a convenience item and are not considered 
primarily medical in nature. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pay for a stair glide.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehab. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee underwent hip 
surgery on January 13, 2021. The physical therapy note states she needs contact guard assist to walk 40 feet 
and stand up and sit down. She needs varied assist with activities of daily living. 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. 
 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve coverage of a clinical trial. 
 
You asked the Plan to pre-approve the trial. You say that this is medically necessary. The Plan denied your 
request. The Plan says Original Medicare covers all costs related to a Medicare-approved clinical trial. 
 
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of 
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as 
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in 
Original Medicare and the plan cost-sharing for the same services. 
 
In this case, you asked the Plan to pre-approve the trial as part of a clinical trial. The Plan does not cover 
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-
approve coverage of a clinical trial.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve care from a massage therapist. 
 
You asked the Plan to pre-approve the therapy. You say that your left hip is always in pain and needs this 
therapy to heal. The Plan denied your request. The Plan says massage therapists are not considered qualified 
therapy professionals, and may not bill their services under the Medicare therapy benefit. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pre-approve care from a massage therapist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) 
for the enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services could be provided in another setting, such as an acute rehab 
facility, skilled nursing facility, nursing facility, outpatient setting, or home care. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found based on the notes, the enrollee appears to be stable and improving but requires only 
a short extension of acute care services which can be safely administered at the current facility. The enrollee 
does not require services at the LTACH that are not already available and covered at the current facility. 
Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to 
a lower level of care may be considered when treatment has completed. 
 
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services beyond January 
21, 2021. 
 
You asked the Plan to pre-approve these services. You say that the enrollee needs to stay in the SNF longer. 
The Plan denied your request. The Plan says the continued services are 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 these services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not have complex 
wound care, intravenous (IV) antibiotics, new enteral feedings, or other skilled nursing needs. He does not 
require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. She does not require 
skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the 
necessary services on an inpatient basis at the SNF level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services beyond January 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Gammagard injections. 
 
You asked the Plan to pre-approve Gammagard injections. You say that the enrollee has 
hypogammaglobulinemia. The Plan denied your request. The Plan says the coverage criteria has not been met. 
 
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 Gammagard injections. Our reviewer 
says that the records provided do not support that the enrollee has a condition that supports the use of IVIG. 
Our physician reviewer found that the members IgG levels were normal, and the records do not demonstrate 
CVID or a similar immunodeficiency that supports the use of the drug. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gammagard injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Gammagard injections.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasound for breast cancer screening. 
 
You asked the Plan to pre-approve these services. You say that you have had many failures with mammograms. 
The Plan denied your request. The Plan says the services are not covered as screening. 
 
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 test at issue in this appeal, an ultrasound, is being requested solely for screening purposes. Medicare does 
not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-
approve an ultrasound for breast cancer screening.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 180 test strips every three months. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that high utilization test strips are covered when 
specific criteria are met. 
 
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 services are not medically necessary. Our physician reviewer found the submitted records show that you 
have type II diabetes and are maintained on Metformin in the evening and Janumet in the morning. Your blood 
glucose ranges from 99 to 128. You deny any low blood sugar readings. The criteria for coverage of test strips 
for high utilization are not met and the services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve 180 test strips every three months.