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

 
We decided that the Plan does not have to pre-approve the additional mileage for routine transportation 
services. 
 
You asked the Plan to pre-approve the additional mileage for routine transportation services. You say that you 
need additional mileage covered. The Plan denied your request. The Plan says each one-way trip must not 
exceed 75 miles of driving distance. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation at a maximum of 75 miles for each one-way trip. 
 
We looked at your request, the records in the case file, and the rules. The file indicates that you are requesting 
additional miles over the 75-mile benefit for routine transportation services. Based on this information, we 
decided that the Plan?s rules for coverage of routine transportation have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the additional mileage for routine transportation services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an all-white crown on tooth #8 and #9. 
 
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 medical records do not demonstrate significant breakdown or pathologic destruction. 
 
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 present with a 
request for crowns on teeth #8 and #9.  Both teeth have existing two surface restoration on the mesial and distal 
surfaces, and it appears #8 has some incisolingual wear from the x-ray view.  There is not extensive incisal 
breakdown on either tooth, however. In this instance there is insufficient damage to the remaining tooth 
structure as to require a full coverage restoration. A conventional composite restoration would adequately 
repair the teeth with a substantial amount of intact structure remaining. There would not be medical necessity 
for the requested crowns. 
 
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 an all-white crown on tooth #8 and #9.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for vision services received on September 9, 2020. 
 
You asked the Plan to pay for the services. You say that the benefit has not been used. The Plan denied your 
request. The Plan says the maximum benefit has been exhausted. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services with a maximum benefit of $70 per year for eyewear and $105 for 
contact lenses. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
We looked at the file and the Plan's rules. The records show that the plan benefit of $70 was paid for routine 
eyewear on the date of service at issue in this case. As the benefit has been exhausted, the remaining balance is 
your responsibility. 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 pay for vision services received on 
September 9, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a PET scan for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says the guidelines do not support PET imaging for initial staging of prostate 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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found there is no confirmed 
diagnosis of prostate cancer. Even if there was, PET/CT is not approved as an initial prostate 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 the scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a PET scan for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tumor imaging with CPT code 78803 provided on June 
24, 2020. 
 
You asked the Plan to pay for CPT code 78803. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that  for Medicare to consider coverage and payment 
for any item or service, the  information submitted by the supplier or provider must confirm that Medicare  
coverage criteria have been met. 
 
We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that 
two separate tumor imaging were provided on June 24, 2020. The file shows that the Plan paid for one tumor 
imaging (1 unit of 78803) provided on June 24, 2020. Therefore, we decided that the Plan does not have to pay 
for the tumor imaging with CPT code 78803 provided on June 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Palonosetron HCL, Carboplatin, Paclitaxel, and 
Dexamethasone Sodium Phosphate. 
 
You asked the Plan to pre-approve Palonosetron HCL, Carboplatin, Paclitaxel, and Dexamethasone Sodium 
Phosphate. You say that you would like the plan to reconsider their denial. The Plan denied your request. The 
Plan says the requested drugs are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Palonosetron HCL, Carboplatin, 
Paclitaxel, and Dexamethasone Sodium Phosphate. Our reviewer says that the documentation does not support 
that the requested drugs are medically reasonable or necessary. Our physician reviewer found the requested use 
of Palonosetron HCL, Carboplatin, Paclitaxel, and Dexamethasone Sodium Phosphate is not FDA-approved for 
the enrollee's diagnosis after progression on same region. Therefore, the requested drugs 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 Palonosetron HCL, Carboplatin, Paclitaxel, and Dexamethasone Sodium 
Phosphate have not been met. Therefore, we decided that the Plan does not have to pre-approve Palonosetron 
HCL, Carboplatin, Paclitaxel, and Dexamethasone Sodium Phosphate.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee on March 9, 2020 to 
March 12, 2020. 
 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be paid for. The Plan 
denied your request. The Plan says that there is no documentation of cellulitis over a prosthesis or implanted 
device or orbital cellulitis. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital services provided to the enrollee on March 9, 2020 to March 12, 2020. 
  
 
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 pre-approve dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you have a lot of gum bleeding and pain. 
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.  
 
The file shows that dental crowns, core buildup, and periodontal scaling and root planing were requested. 
Although the Plan offers a dental benefit that exceeds Medicare coverage, these services are not among those 
covered under the plan. Based on this information, we decided that the Plan?s rules for coverage of dental 
services have not been met.  
 
The file shows that a filling for tooth #12 was requested. We looked at the file, and rules. The records show 
that you were previously approved for 2 fillings. Your plan only covers 2 fillings per year. Based on this 
information, we decided that the Plan's rules for coverage of the fillings have not been met. Therefore, we 
decided that the Plan does not have to pre-approve dental services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) 
rendered by the out of network (OON) provider on July 9, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out of network 
(OON) provider on July 9, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 23, 2020, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the OON services. You say that testing can be used to assess risk, and minimize 
adverse outcomes. The Plan denied your request. The Plan says the enrollee's plan requires utilization of 
network providers, and authorization for certain services. 
 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve 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 the lab services provided on March 23, 2020, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the x-ray provided on May 19, 2020. 
 
You asked the Plan to reduce the copayment for the x-ray. You say that you should only be charged a $15 
copayment for the x-ray and not a $30 copayment for an office visit. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 
copayment for all other diagnostic procedures and tests at all locations of service. For this date of service, you 
have been asked to pay the allowed amount of the claim because this amount is less than the $75 copayment for 
the x-ray. 
 
You have been asked to pay a $30.33 copayment for the x-ray. The x-ray falls within ?Outpatient diagnostic 
tests and therapeutic services and supplies? benefit category. The record shows you received the x-ray at an 
office visit and not at an IDTF.  
 
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 reduce the copayment for the x-ray provided on May 19, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device. 
 
You asked the Plan to pre-approve surgery to place a Vertiflex Superion device. You say that you would like 
the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 surgery to place a Vertiflex Superion 
device. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the enrollee has a history of other intervertebral disc 
degeneration, lumbar region. The requested spacer remains experimental. More research is needed to show 
safety and efficacy of the device. Therefore, the enrollee does not meet criteria for the requested device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of surgery to place a Vertiflex Superion device have not been met. Therefore, we 
decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says needs could be met a lower level of care. 
 
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 your nursing, medical and rehabilitation needs does not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
weakness. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are 
no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record documents a need for physical and occupational therapy, it does not document a need for an intensive 
rehabilitation program. There is no reasonable expectation that you will be able to fully participate in and 
benefit from the 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).
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 would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the requested admission 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 the enrollee was admitted to the current acute care hospital with acute hypoxic 
respiratory failure secondary to CoViD-19 pneumonia. He was treated with intubation and later tracheostomy. 
The course was complicated by Klebsiella pneumonia and empyema treated with antibiotics and chest tube. 
Recent notes show that the enrollee had the chest tube removed and he has been weaned to 28% trach collar 
successfully. The documentation does not support that the enrollee requires services at the LTACH that are not 
available at the acute care hospital where the enrollee is currently receiving care. There are no services 
available at the LTACH that the enrollee requires that are not available at the health care setting being offered 
by the health plan. 
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) (E0745) provided on June 8, 2020.

You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that a transcutaneous electrical nerve stimulator (TENS) and supplies for the treatment of chronic low back pain are not a covered benefit under the enrollee's contractual policy or by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a TENS device is not reasonable and necessary for the treatment of chronic low back pain (CLBP).  

We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Specifically, the claim was billed with a primary diagnosis code for chronic low back pain. Medicare rules state that a TENS device is not reasonable and necessary for the treatment of chronic low back pain. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical nerve stimulator (TENS) (E0745) provided on June 8, 2020.
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 LTACH care is medically necessary. The 
Plan denied your request. The Plan says rules for LTACH care have not been met. 
 
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 the patient appears to be more stable and improving but requires additional short-
term acute care services which can safely be administered at the current facility. The patient 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 patient requires that are not already available and covered at the current facility. Transfer 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 long-term acute care hospital (LTACH) services.