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

 
We decided that the Plan has to pre-approve Keytruda for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is covered when there is a diagnosis of small cell lung cancer that has worsened 
on or after platinum-based therapy, and at least one or more prior line of therapy. 
 
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 the drug. Our reviewer says that the 
requested drug is medically reasonable and necessary. Our physician reviewer found DrugDex lists orphan 
drug status for Keytruda for small cell lung cancer without specifying additional factors. The NCCN Guideline 
Version 1.2021 Small Cell Lung Cancer page SCL-E 2 of 5 indicates that for patients who relapse more than 6 
months after initial treatment, the preferred regimen is the original treatment. The enrollee's original treatment 
was chemotherapy with Carboplatin/Etoposide. The same page notes that if relapse occurs earlier, 
Pembrolizumab is a recommended treatment. Therefore, since the enrollee cannot tolerate additional 
chemotherapy, given the DrugDex citation and the NCCN guidelines, the documentation supports that 
Keytruda is medically reasonable and necessary and safe and effective for the enrollee. 
 
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 drug have been met. Therefore, we decided that the Plan has to pre-approve 
Keytruda for 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
non-participating provider on May 2, 2019. 
 
You asked the Plan to waive the coinsurance for durable medical equipment. You say that you do not agree 
with this coinsurance. The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay less than a 20% coinsurance of the allowed amount for durable medical 
equipment. The total allowed amount is $2,899.50. The total 20% coinsurance is $579.90 ($2,899.50 x 20% = 
$579.90). The total amount you are being asked to pay is $294.50. Durable medical equipment falls within the 
durable medical equipment 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 coinsurance for durable 
medical equipment provided by a non-participating provider on May 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the rebase of a complete upper denture (D5710). 
 
You asked the Plan to pre-approve the dental service. You say that part of your upper denture needs to be 
repaired. You say that there is a hole. You also say that food gets stuck inside the hole. The Plan denied your 
request. The Plan says rebase of a complete upper denture is not listed as a covered 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 pre-approve the 
rebase of a complete upper denture (D5710).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say 
that your current dentures do not fit. The Plan denied your request. The Plan says these services exceed the 
maximum count allowed per period. 
 
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, complete maxillary denture (D5110) 
and complete mandibular denture (D5120) and are each limited to one procedure every five plan years. The 
record shows that you received a complete maxillary denture (D5110) and a complete mandibular denture 
(D5120) on March 19, 2019, and your complete maxillary denture (D5110) and complete mandibular denture 
(D5120) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a 
complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #31. 
 
You asked the Plan to pre-approve the crown. You say that you need a new crown. The Plan denied your 
request. The Plan says five years have not passed since you received the last crown on tooth #31. 
 
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, crowns are limited to one every five 
years. The record shows that you received a crown on tooth #31 on April 1, 2019, and your crown benefit for 
tooth #31 has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown 
(D2740) for tooth #31.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular risk assessment provided on March 28, 
2020. 
 
You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like the plan to 
reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered 
benefit. 
 
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 cardiovascular risk assessment test at issue in this appeal was 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 pay for the cardiovascular risk assessment provided on March 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging, pelvis (72197) and gadoterate 
meglumine injection (A9575) provided July 2, 2020. 
 
You asked the Plan to pay for the radiology services. You say that you thought that this would be covered in 
full and did not realize there would be any patient responsibility. You did not know you had to make sure they 
were in network first. The Plan denied your request. The Plan says the yearly out of network deductible is 
$500. Until you have paid the deductible amount, you must pay the full cost for most of your out-of-network 
covered services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there $500 out of network deductible.  
 
The item or service you asked the Plan to pay for falls within the benefit category Outpatient hospital services. 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is $500 out of network 
deductible. Until you have paid the deductible amount, you must pay the full cost for most of your out-of-
network covered services. This cost sharing is a contractual obligation that had not been met at the time the 
radiology services was received on July 2, 2020. Therefore, we decided that the Plan does not have to pay for 
magnetic resonance imaging, pelvis (72197) and gadoterate meglumine injection (A9575) provided July 2, 
2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided on June 15, 
2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray. You say that this was our first dental 
cleaning of the year. You also say that the Plan covers the entire cleaning, including the x-ray. The Plan denied 
your request. The Plan says the benefits for this service have been satisfied and the frequency limitation has 
been exceeded. 
 
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 
additional intraoral periapical x-ray provided on June 15, 2020.  
 
The Plan contacted the providers office, and it was confirmed that your account was adjusted for the additional 
intraoral periapical x-ray, and the $25.00 charge was no longer showing as member responsibility. The 
provider?s office confirmed that you have an account balance of $0.00.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on December 16, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 
 
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 laboratory testing at issue in this appeal was 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 pay for the 
laboratory services provided on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) provided on March 12, 
2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for the outpatient office visit. You say that you are appealing because you are being 
seen by a different provider and have not seen this doctor. The Plan denied your request. The Plan says 
enrollee's must receive their medical services from an in-network provider with the exception being urgent or 
emergent services. Non-emergent services with non-contracted providers require prior authorization before 
services being rendered. 
 
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 the outpatient office visit (99213) provided on 
March 12, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided April 6, 2020, to April 7, 
2020. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient service was medically 
necessary. The Plan denied your request. The Plan says that the enrollee's stay was consistent with 
observational level of care. 
 
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 this elderly enrollee was severely traumatized with brain injury from bleeding, rib fractures, 
and flank hematoma. Given the age and serious nature of injuries and potential for worsening, it is reasonable 
and expected that the enrollee was admitted. This denial is overturned. 
 
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 the acute inpatient hospital care provided April 6, 2020, to April 7, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for durable medical equipment provided by a 
participating provider on May 26, 2020. 
 
You asked the Plan to waive the coinsurance for a wheelchair. You say that you did not know it was a rental. 
The Plan denied your request. The Plan says the correct coinsurance 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 20% 
coinsurance for durable medical equipment.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for a wheelchair. The total allowed 
amount is $95.32. The total amount you are being asked to pay is $19.06 ($95.32 x 20% = $19.06). A 
wheelchair falls within the durable medical equipment 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 coinsurance for durable medical equipment provided by a participating provider on May 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled home health services coded as G0151, G0299, 
G0156 and Q5001 provided September 25, 2019 to September 26, 2019. 
 
You asked the Plan to pay for the skilled home health services. You say that please see the attachment indicting 
hospice services terminated on 09/17/2019. The Plan denied your request. The Plan says Original Medicare 
would be responsible for payment of all Medicare covered services related or unrelated to the member?s 
terminal condition until the first day of the month following the month in which hospice was revoked or 
discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
 
 
The enrollee ended Medicare Hospice benefits on September 17, 2019. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the skilled home 
health services coded as G0151, G0299, G0156 and Q5001 provided September 25, 2019 to September 26, 
2019.
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 benefit from an inpatient 
rehabilitation. 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 the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer 
found that the enrollee does require physical therapy and occupational therapy services, but based on the 
medical records provided, the enrollee does not require an intensive inpatient rehabilitation therapy program. 
Our physician reviewer also found that there is no documentation that the enrollee requires the intensive 
rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility 
level appears to be more appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services you received on June 11, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider has opted 
out of Medicare. 
 
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 a provider that 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
services you received on June 11, 2020.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve selective internal radiation therapy (SIRT) for the enrollee. 
 
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your 
request. The Plan says that research has not shown that the requested type of treatment would improve the 
outcome. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 therapy. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee's disease has progressed while on systemic therapy and melanoma is historically 
unresponsive to chemotherapy which is a potentially toxic therapy that is unlikely to be as efficacious or 
tolerable as liver directed therapy. Liver directed therapy may or may not prolong life, and certainly will not 
cure the condition, but it has a reasonable likelihood of preventing (or delaying) symptomatic progression. For 
this enrollee, standard treatment options of systemic therapy have been exhausted leaving only clinical trials as 
an option.  As radioembolization is an accepted standard in patients with chemo-refractory disease, this 
treatment would be furnished in accordance with accepted standards of care in this patient with liver-dominant 
disease. This request falls within the standards of care, based on the body of published literature. 
 
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 therapy have been met. Therefore, we decided that the Plan has to pre-
approve selective internal radiation therapy (SIRT) for 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a 
participating provider on February 27, 2020. 
 
You asked the Plan to waive the copayment for a biopsy. You say that no one told you that you would owe this 
amount. 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 $395 
copayment for outpatient surgery/in-network.  
 
You have been asked to pay a $395 copayment for a biopsy. A biopsy falls within the outpatient surgery/in-
network 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 an outpatient surgery 
provided by a participating provider on February 27, 2020.