Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve sinus surgery. We decided that the Plan does not have to pre-
approve septoplasty and turbinate reduction.  
 
You asked the Plan to pre-approve sinus surgery. You say that this is medically necessary. The Plan says that 
further interventions are not supported by the clinical information submitted. 
 
We decided that the Plan has to pre-approve sinus surgery.  
 
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 for sinus surgery. Our reviewer says that sinus 
endoscopic surgery is medically reasonable and necessary. Our physician reviewer found that the enrollee 
appears to be suffering from recurrent acute sinusitis which could warrant endoscopic sinus surgery to help 
prevent future infections. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of sinus surgery have been met. Therefore, we decided that the Plan has to pre-
approve sinus surgery.  
 
We also decided that the Plan does not have to pre-approve septoplasty and turbinate reduction. 
 
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 for septoplasty and turbinate reduction Our reviewer 
says that these procedures are not medically reasonable or necessary. The physician saw the enrollee several 
times in 2020, but an intranasal exam was never documented in any of the nose. There is no documentation 
supporting that the enrollee has a deviated septum. The CT says the septum is "unremarkable" and the 
physician states that the nose is normal in all of his physical exams. In one note he writes "nose blockage" but 
does not give any further description of the septum or the inferior turbinates. The CT does not support the 
diagnosis of chronic sinusitis. The mucus retention cyst on the right will not contribute to a nasal blockage on 
the left. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of septoplasty and turbinate reduction have not been met. Therefore, we decided 
that the Plan does not have to pre-approve septoplasty and turbinate reduction. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a segmented pneumatic compression device for the 
enrollee. 
 
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says Medicare requires an appropriate good faith attempt with E0650 or E0651. 
 
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 device. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support lymphedema of the chest, trunk, or abdomen on an objective 
physical exam. There are no unique characteristics that would indicate the segmented pump over a standard 
pump. There is no documentation of a four week trial and failure of the standard pump. The criteria for an 
E0652 pump has not been met. 
 
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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a segmented pneumatic compression device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance transport provided on March 
21, 2020. 
 
You asked the Plan to waive the copayment for the ambulance transport. You say that you are on disability and 
struggling to pay bills. 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 $350 
copayment for Medicare-covered ambulance services per trip.  
 
You have been asked to pay a $350 copayment for the ambulance transport. The ambulance transport falls 
within the ?Ambulance services? 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 ambulance transport provided on March 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of residual tooth roots (cutting procedure) (D7250) 
and alveoloplasty in conjunction with extractions - four or more teeth or tooth (D7310) provided on January 10, 
2020. 
 
You asked the Plan to pay for removal of residual tooth and alveoloplasty. You say that the service was 
medically necessary. The Plan denied your request. The Plan says you do not have coverage for non-emergent 
care outside of the Country. 
 
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. You may see any licensed 
dental provider who accepts Medicare patients in the U.S and has not opted out of Original Medicare. 
 
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. Specifically, there is no records indicating the care you received 
outside of the Country was emergent, and therefore, the services received are not covered benefits. Therefore, 
we decided that the Plan does not have to pay for removal of residual tooth roots (cutting procedure) (D7250) 
and alveoloplasty in conjunction with extractions - four or more teeth or tooth (D7310) provided on January 10, 
2020.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee is at a prior level of function, and is appropriate for discharge. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found that you do not require skilled nursing 
services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely 
and effectively provide medically necessary and reasonable treatment in a SNF.  You do not have complex 
wound care or other ongoing SNF level SN need. Your functional level 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. You do not require skilled nursing or skilled 
therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do 
not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the risk assessment panel provided. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, 
except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or 
documented CV disease because panel testing is not specific to a given patient?s lipid abnormality or disease. 
 
We looked at the file and Medicare rules. Per L36523, the requested risk assessment panel is non-covered. 
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 risk assessment panel provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist telehealth services provided by a 
participating provider on June 24, 2020. 
 
You asked the Plan to waive the copayment for specialist telehealth services. You say that you had no services 
provided. The Plan denied your request. The Plan says the correct copayment has been applied. 
 
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 $40 
copayment for physician/practitioner services/specialist visit.  
 
You have been asked to pay a $40 copayment for specialist telehealth services. Since a telehealth call took 
place, the correct copayment has been applied. Specialist telehealth services fall within the 
physician/practitioner services/specialist visit 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 specialist telehealth services provided by a participating provider on June 24, 2020.  
 
We note your complaint about lack of care. Your complaint is a grievance that must be answered by the health 
plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extension of coverage of a negative pressure wound 
therapy (NPWT) pump for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there has been no measurable degree of wound healing over the past month. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this case, following Medicare coverage guidelines, a negative pressure wound therapy pump (wound 
vac) is no longer covered when there has been no measurable degree of wound healing over the past month. 
The records received indicate that the size of the wound has increased in the last 30 days while the wound vac 
has been in use, which indicates that the wound is not healing. Alternate treatment options should be 
considered. The review has determined that the enrollee has not received proper wound healing to indicate 
continued coverage. The enrollee does not meet the above criteria for continue coverage of a negative pressure 
wound therapy (NPWT) pump. 
 
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 pre-approve extension of coverage of a negative pressure wound therapy (NPWT) pump for the 
enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Atezolizumab and Bevacizumab. 
 
You asked the Plan to pre-approve Atezolizumab and Bevacizumab. 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 FDA-
approved 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 Atezolizumab and Bevacizumab. Our 
reviewer says that the documentation does not support that the requested drugs are medically reasonable or 
necessary. Our physician reviewer found the enrollee incurable pancreatico-biliary cancer. Her biopsy 
specimen was reviewed by two independent pathologists who agreed. The use of this combination is not FDA 
approved for pancreatico-bliliary cancer. The requested us is not supported in any of the CMS approved 
compendia. Therefore, the enrollee does not meet criteria for the requested drugs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Atezolizumab and Bevacizumab have not been met. Therefore, we decided that 
the Plan does not have to pre-approve Atezolizumab and Bevacizumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the surgical extraction (D7210) provided on June 
30, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that the provider advised that you would 
be reimbursed by your insurance for the services. You say that you did not think that was right. The Plan 
denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that 
services rendered by dentists who have opted out or been excluded from Medicare are not eligible for 
reimbursement. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for 
the surgical extraction (D7210) provided on June 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical removal of a dental implant (D6100), bone 
replacement grafting (D7953), and guided tissue regeneration (D4266) for tooth site 27. 
 
You asked the Plan to pre-approve the requested dental services. You say that you need this implant removed 
as you have an infection, and you were told this can cause health problems. The Plan denied your request. The 
Plan says the requested services are not medical in nature and are not covered by your supplemental dental 
benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical removal of a dental implant (D6100), bone replacement grafting (D7953), and guided tissue 
regeneration (D4266) for tooth site 27.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says Entity  needs are custodial in nature. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled 
nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to 
safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not 
have complex wound care or other ongoing SNF level SN need. The enrollee's functional level 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. The enrollee is ambulating 400 
feet SBA. He will need 24/7 supervision at home due to poor safety awareness. The enrollee does not require 
skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a 
practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing 
facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital services provided to the enrollee. 
 
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 was not an approved authorization. 
 
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 enrollee's condition was sufficiently complex and ill. Inpatient hospital care on these dates 
of service was medically necessary and indicated. Hospitalization was justified on these dates. 
 
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. 
  
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: 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 the services can be safely received in other settings, for example: a 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 you do not require the intensity of services provided at an IRF.  Specifically, you are 
not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your 
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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3020). 
 
You asked the Plan to pre-approve foot orthotics. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this item is not a covered benefit under your 
contractual policy for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).