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

 
We decided that the Plan does not have to pre-approve Orencia Clickject 125mg/ml. 
 
You asked the Plan to pre-approve Orencia Clickject. You say that the enrollee has severe, active rheumatoid 
arthritis. You say that the enrollee has tried and failed other drugs. You say that the enrollee is currently using 
this drug. You also say that the enrollee needs this to manage their disease. The Plan denied your request. The 
Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered 
under a Medicare Part D prescription drug plan. The Plan says the requested drug is not covered under 
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 Orencia Clickject 
125mg/ml.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the preventive procedure (D1999) and maxillary implant 
/abutment supported removable denture for edentulous arch (D6110) provided on June 5, 2020. 
 
You asked the Plan to pay for the preventive procedure and maxillary denture. You say that you cannot afford 
to pay out of pocket for all of these services. You also say that you thought the services being authorized meant 
that all of it would be paid. The Plan denied your request. The Plan says these 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. 
 
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 the 
preventive procedure (D1999) and maxillary implant /abutment supported removable denture for edentulous 
arch (D6110) provided on June 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive periodontal evaluation (D0180). 
 
You asked the Plan to pre-approve a comprehensive periodontal evaluation. You say that you have pain around 
tooth # 30. You say that you have had issues since you had a root canal. You say that tooth # 14 has a large 
crack in the middle that is being held together by an old filling. You also say that you would like to save this 
tooth. The Plan denied your request. The Plan says comprehensive periodontal evaluation is not listed as a 
covered service. The Plan also says any services not listed 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested comprehensive 
periodontal evaluation is not among those covered under this benefit. Additionally, the Evidence of Coverage 
clearly states that any services not listed are not covered. Therefore, we decided that the Plan does not have to 
pre-approve a comprehensive periodontal evaluation (D0180).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will clearly benefit from acute rehab to 
optimize his level of functioning prior to returning home. The Plan denied your request. The Plan says the IRF 
services you are requesting do not meet the requirements for approval. 
 
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 there is no evidence of medical issues that require monitoring by an inpatient rehab 
physician three times a week. Our reviewer found that the documentation does not support that there is a need 
for an intensive therapy program with 3 hours a day and an interdisciplinary approach to rehab care. Our 
physician reviewer also found that the enrollee's rehab needs can be met in an alternate, less intense 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99285) provided February 25, 
2020. 
 
You asked the Plan to pay for the emergency room services. You say that CPT code 99285 was correctly billed. 
The Plan denied your request. The Plan says the documentation does not support CPT code 99285. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99285 is Emergency Room Visit for the evaluation and 
management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with 
other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) 
and the patient's and/or family's needs. Usually, the presenting problems(s) are of high severity and pose an 
immediate significant threat to life or physiologic function for reimbursement consideration. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, the record does not support 
that the enrollee had problems of a high severity and that services were of a high complexity. CPT code 99284 
is appropriate for the services at issue. Based on this information, we decided that Medicare rules for coverage 
of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay 
for emergency room services (99285) provided February 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary/rest home visit services provided to the enrollee 
on April 30, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Medicare says non-urgent services should be from network providers who are contracted with 
the healthplan and listed in the Provider Directory. 
 
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 has network providers 
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for domiciliary/rest home visit services provided to 
the enrollee on April 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient cardiac catheterization 
services you received from July 15, 2020, to July 16, 2020. 
 
You asked the Plan to waive the coinsurance for the outpatient cardiac catheterization services. You say that 
this procedure was supposed to be done when you were an inpatient from July 2, 2020, to July 3, 2020.  You 
say that the hospital was unable to get authorization or find an anesthesiologist due to the holiday. You had to 
return to have this done as an outpatient.  You said that it wasn't your fault that this was done as an outpatient, 
so you shouldn't have to pay the coinsurance. The Plan denied your request. The Plan says you were charged 
this coinsurance 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 20% 
coinsurance for outpatient surgery or services provided at hospital outpatient facilities.  
 
You have been asked to pay 20% coinsurance for the outpatient cardiac catheterization services. The outpatient 
cardiac catheterization services falls within the outpatient surgery or services provided at hospital outpatient 
facilities benefit category. This cost sharing applies regardless of the reason for it being provided in an 
outpatient setting. 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 coinsurance for the outpatient cardiac 
catheterization services you received from July 15, 2020, to July 16, 2020.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve an MRI (73721) of the left knee. We decided that the Plan does 
not have to pre-approve an MRI of the right knee.  
 
You asked the Plan to pre-approve an MRI (73721) of the left knee. You say that an MRI of the left knee is 
medically necessary. The Plan says that the clinical information provided does not meet this criterion. 
 
Our doctor found that the documentation supports an MRI of the left knee. Our doctor did not see 
documentation requesting or supporting an MRI of the right knee. The left knee MRI is approved/indicated. 
 
Therefore, we decided that the Plan has to pre-approve an MRI (73721) of the left knee. 
We also decided that the Plan does not have to pre-approve an MRI (73721) of the right knee.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by the
Fire Department on February 16, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you fell and broke your arm and the medics 
treated you in place. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on February 16, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by the Fire Department on February 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for orthotics (L1851, L2385, L2397) provided April 3, 2020. 
 
You asked the Plan to pay for the orthotics. You say that the items were medically necessary. The Plan denied 
your request. The Plan says the documentation did not included sufficient proof of delivery. 
 
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. There was no itemized billing or shipping receipt that 
noted the items shipped and the date of service. 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 
orthotics (L1851, L2385, L2397) provided April 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography angiography (CTA) of 
abdomen and pelvis. 
 
You asked the Plan to pre-approve a CTA of abdomen and pelvis. You say that the only way to evaluate the 
enrollee's condition is on CTA imaging. The Plan denied your request. The Plan says the information submitted 
does not support the requirements of medical necessity guidelines. 
 
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CTA of abdomen and pelvis. Our 
reviewer says that a CTA is not medically necessary. Our physician reviewer found the documentation does not 
support the medical necessity of an additional CT angiogram. While the surgeon appeal is correct in that when 
initially evaluating an abdominal aortic aneurysm (AAA) regardless of size, CTA is helpful to demonstrate the 
morphology of the aneurysm as if the aneurysm was indeed saccular or in fact a pseudo aneurysm treatment 
would be different and not based on size criteria alone. However, the enrollee has had a CTA in the relatively 
recent past. There is a CTA on August 17, 2018 demonstrating an AAA of approximately 3.7 cm in transverse 
dimension. There was an associated office visit with the CTA at that time, and there was no mention of unusual 
morphology or elevated rupture risk. This study should be sufficient to determine the morphology of the 
aneurysm. Yearly CTAs exposes the enrollee to the risks of contrast dye infusion. It is unclear if the requesting 
surgeon was aware of the available CT angiogram. Duplex ultrasound would be a reasonable modality to 
follow the patient with respect to aneurysm size since a CTA was performed. If indeed the CTA from 2018 did 
demonstrate worrisome morphology, that should be documented and this case should be re-reviewed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CTA of abdomen and pelvis have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a CTA of abdomen and pelvis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for 2 additional resin based composites provided on May 20, 
2020. 
 
You asked the Plan to pay for 2 additional resin based composites. You say that you were in an accident. You 
say that you were advised you would only have to pay $500 for the composites. You also say that the trauma 
from the accident and medical bills incurred have impacted you emotionally and financially. The Plan denied 
your request. The Plan says 2 fillings per calendar year are covered. The Plan says that the frequency limit has 
been exceeded. The Plan also says that 2 of the 4 fillings were already approved for this date of service. 
 
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 2 
additional resin based composites provided on May 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a behavioral health inpatient admission provided from June 
11, 2020, through  
June 12, 2020. 
 
You asked the Plan to pay for the behavioral health inpatient admission. The Plan denied your request. The 
Plan says all inpatient services require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 a behavioral health inpatient admission provided from June 11, 
2020, through June 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided by you on May 26, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive 
order for treatment in place. The Plan denied your request. The Plan says these services are not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 26, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided by you on May 
26, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on July 15, 2020. 
 
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization.  
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
laboratory services. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for laboratory services provided on July 15, 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 SNF admission. 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 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 SNF admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. 
The enrollee had stable vital signs. The enrollee required supervision with functional mobility including 
walking to 65 feet with a rolling walker. The enrollee required varying assistance with activities of daily living. 
The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of 
a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and 
reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are 
 
 
required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an 
inpatient basis, at a 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 SNF 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient 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 there is no daily skilled nursing or therapy need. 
 
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 there are no identifiable skilled nursing 
service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled 
nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of 
service criteria for 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 inpatient admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on July 23, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-
emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
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 physician's services provided on July 23, 2020.