Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided by an out of 
network (OON) provider. 
 
You asked the Plan to pay for the vision services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent 
nor urgent and prior authorization was not obtained to provide out-of-network care. 
 
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 vision services provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at 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. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says admission to an IRF 
is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs 
do require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee's medical status currently does not require intensive physician and nursing supervision in an IRF. 
While the enrollee may benefit from additional physical and occupational therapy, the documentation does not 
support that the enrollee's functional level requires or can fully tolerate this therapy on an IRF level. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need therapy. The Plan denied your request. The 
Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture 
after a fall. Your 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 not a reasonable expectation that you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician 
reviewer found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve an implantable loop recorder. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says that the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are medically necessary. Our physician reviewer found the enrollee has infrequent symptoms of 
dizziness and near syncope. Her monitor has shown bradycardia but no evidence of symptomatic 
disease. She is on beta blocker therapy which cannot be discontinued owing to a life limiting tremor which 
develops when she is not on a relatively high dose of propranolol.  As she requires high dose beta blockers, has 
bradycardia at baseline and infrequent near syncope, an evaluation for symptomatic bradycardia is reasonable 
since the beta blocker cannot be discontinued. Given the infrequent nature of the symptoms, the implantable 
loop recorder would likely have the highest diagnostic yield of any of the alternative longer term diagnostic 
devices in this clinical situation. The services are reasonable and medically necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-
approve an implantable loop recorder.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on August 20, 2020. 
 
You asked the Plan to pay for the dental services. You say that prior to receiving these services you were told 
that you were covered for up to $2,000 per year for dental services. You also say that you found out after you 
received the services that you only had $1,000 maximum dental coverage per year. The Plan denied your 
request. The Plan says you have already been reimbursed $1,000 for your non-Medicare covered dental 
services. The Plan also says that you were correctly advised of your Plan's $1,000 maximum reimbursement for 
dental services on February 25, 2020. 
 
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 Plan offers a $1,000 allowance 
every year for non-Medicare-covered preventive dental services and non-Medicare-covered comprehensive 
dental services combined. You are responsible for any amount above the dental coverage limit. The record 
shows that you met the annual maximum benefit on September 1, 2020, and your annual maximum benefit has 
been exhausted. Therefore, we decided that the Plan does not have to pay for the dental services provided on 
August 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecomputed tomography (CT), thorax (71260).You asked the Plan to pre-approvethe CT scan. You say that you are requesting a CT of the chest for surveillance of chest to confirm no pulmonary metastasis.The Plan denied your request. The Plan says the service requested does not meet the Medicare criteriaand is not medically necessary.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 the CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found for GIST surveillance imaging of the abdomen and pelvis is recommended by the NCCN Guidelines annually after year five. This enrollee is at least sixyears out from initial diagnosis and remains with no evidence of disease. A CT of the chest would not be indicated. The service is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approvecomputed tomography (CT), thorax (71260).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the 
abdomen/pelvis. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee was recently noted to have 
a review of systems positive for dyspepsia, diarrhea, urinary frequency and nocturia. There are no exams of the 
abdomen, pelvis, genitourinary organs, or rectum in the documentation. A gastrointestinal evaluation was 
planned but not yet conducted. The documentation is insufficient to support that that the requested CT scan of 
the abdomen and pelvis is currently medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the panoramic x-ray (D0330) provided. 
 
You asked the Plan to pay for the panoramic x-ray. You say that x-rays were taken because you went to a new 
dentist. You also say that you feel this should be covered because these problems happened shortly before you 
saw the new dentist. The Plan denied your request. The Plan says that this service exceeds the frequency 
limitation in your benefit plan. 
 
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.  
 
We looked at the file and Medicare rules. The contract says that panoramic x-ray (D0330) is limited to one 
procedure per plan year. The record shows that you received a panoramic x-ray (D0330), but does not show that you received a panoramic x-ray (D0330) prior to this date of 
service during the 2020 plan year. Based on this information, we decided that the Plan's rules for coverage of 
the panoramic x-ray have been met. Therefore, we decided that the Plan has to pay for the panoramic x-ray 
(D0330) provided.  
 
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 guided tissue regeneration (D4266). 
 
You asked the Plan to pre-approve guided tissue regeneration. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the service is not a covered 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. Covered services are listed in 
the Plan?s EOC. 
 
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, the service requested is not listed in the Plan?s EOC, and 
therefore, is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve guided 
tissue regeneration (D4266).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for knee orthoses (L1833, L2397), wrist hand orthosis (L3916) 
and shoulder elbow wrist hand orthosis (L3960) provided on August 5, 2020. 
 
You asked the Plan to pay for the orthoses. You say that you would like reconsideration because these supplies 
are medically necessary. The Plan denied your request. The Plan says there is no evidence of an established 
relationship between the member and provider. 
 
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 pay for the orthoses. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no evidence of an established relationship between the enrollee and provider; the 
provided records are not clearly a reflection of a face-to-face examination of the enrollee or of a tele-health 
visit with the enrollee. The documentation contains numerous apparent errors that make no clinical sense 
 
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 orthoses have not been met. Therefore, we decided that the Plan does not 
have to pay for knee orthoses (L1833, L2397), wrist hand orthosis (L3916) and shoulder elbow wrist hand 
orthosis (L3960) provided on August 5, 2020.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve MRI of the abdomen. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no information that other tests such as CT was not normal and could not help 
identifying the problem. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found a review of the records 
shows mention of a prior CT of the abdomen without contrast but no report of this exam is in the records. 
Without such a report authorization of MRI would not be possible. More importantly, review of your records of 
9/1/20 shows you have an indwelling thoracic spine stimulating device which would likely represent a 
contraindication to MR imaging of any kind. For these reasons, MRI of the abdomen should not be approved at 
this point in time. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve MRI of the abdomen.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient hospital care provided from July 13, 2018, through July 16, 
2018, and billed with DRG code 193. 
 
You asked the Plan to pay for the inpatient hospital care. You say that you would like reconsideration because 
the services rendered were medically necessary, The Plan denied your request. The Plan says that there is 
insufficient clinical evidence in the records to substantiate acute respiratory failure. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG.  
 
In this case, you billed the services provided July 13, 2018, through July 16, 2018. with DRG 193. 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 the inpatient hospital care. Our reviewer says that the 
documentation supports a diagnosis of acute respiratory failure with hypoxia. Our physician reviewer found at 
the time of admission, the member required increase in oxygen supplementation to 4 L/min to maintain 
adequate oxygen saturation. 
 
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 inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for inpatient hospital care provided from July 13, 2018, through July 16, 2018, and billed with DRG 
code 193.  
 
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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Carboplatin, Etoposide IV, Durvalumab, Fosaprepitant IV, 
Ondansetron IV, Dexamethasone and Pegfilgrastim-CBQV for the enrollee. 
 
You asked the Plan to pre-approve these drugs. You say that this is needed for the treatment of the member?s 
malignant neoplasm of the bladder. The Plan denied your request. The Plan says that that the use of this drug in 
your case requires carboplatin, etoposide, and durvalumab (IMFINZI) will not be used in combination for the 
treatment of bladder cancer. 
 
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 these drugs. Our reviewer says that 
these drugs are medically reasonable and necessary for the enrollee in this case. The use of these drugs is FDA 
approved for the enrollee's diagnosis. Small cell bladder cancer that is metastatic is treated as if it was an 
extensive stage small cell lung cancer. The documentation supports that the requested drugs are safe and 
effective and otherwise reasonable and necessary for this enrollee. Our physician reviewer found that the 
enrollee's condition meets Medicare criteria for coverage of these 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 these drugs have been met. Therefore, we decided that the Plan has to pre-
approve Carboplatin, Etoposide IV, Durvalumab, Fosaprepitant IV, Ondansetron IV, Dexamethasone and 
Pegfilgrastim-CBQV 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.