Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a referral to a tertiary-level radiation oncologist. 
 
You asked the Plan to pre-approve these services. You say that you are an established patient of this provider. 
The Plan denied your request. The Plan says the tertiary level of care is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the tertiary level of care is not medically necessary. Our physician reviewer found the submitted records show 
that you need routine follow-up care. There is no compelling evidence in the records to support that a tertiary-
level provider is needed for follow-up care. The services can be provided by a non-tertiary provider. The 
referral to the tertiary-level provider is therefore 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a referral to a tertiary-level radiation oncologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction, tooth #4 (D7140) and limited oral exam (D0140) 
and March 3, 2020. 
 
You asked the Plan to pay for the dental services. You say that you were expecting a refund of $110 since the 
Summary of Benefits indicates the copay is 50% for extractions. Please send a check for the unpaid balance 
due in the amount of $80.50. The Plan denied your request. The Plan says this claim processed correctly with 
the 50% copay for dental extractions. D7140 is covered but the benefit limit 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. Your contract with the plan 
clearly says that you must pay 50% copayment for dental extractions. D0140 is limited to one procedure per 
year. The records show that this service was provided on February 20, 2020. 
 
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 
extraction, tooth #4 (D7140) and limited oral exam (D0140) and March 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit ((99387) provided June 24, 2019. 
 
You asked the Plan to pay for the annual wellness visit. You say that you are appealing because this was a 
follow up from an emergency room visit provided June 5, 2019 and you were told by the ER doctor to get a 
follow up visit with your physician as soon as possible. The Plan denied your request. The Plan says this 
request exceeds the benefit frequency limitation. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. Annual Wellness visits are allowed once every 12 months. The records show that 
this service was provided December 6, 2019 and was already processed and approved for payment. The 
December 6, 2019 claim was paid first because the June 24, 2019 claim was not received until April 22, 2020. 
Based on this information, we decided that Medicare rules for coverage of the annual wellness visit have not 
been met. Therefore, we decided that the Plan does not have to pay for the annual wellness visit ((99387) 
provided June 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of impacted tooth, tooth #18 (D7220) provided 
January 29, 2020. 
 
You asked the Plan to pay for removal of impacted tooth. You say that you have attached copies of the original 
statement for $1610 and the check you received for $216. It is not clear to you why your claim has been denied. 
Please expedite the balance of the refund that you are due. The Plan denied your request. The Plan says this 
service is not covered under the plan benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The health plan contract says 
that services not listed under the list of covered dental procedures are not covered. 
 
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 removal 
of impacted tooth, tooth #18 (D7220) provided January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive dental exam (D0150) and intraoral x-rays 
(D0220, D0230, D0350) provided March 10, 2020. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the benefit for a comprehensive oral exam was exhausted prior to the 
service at issue. Intraoral x-rays are not covered under your 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. The benefit for a comprehensive dental exam was exhausted on 
January 15, 2020. Plan coverage for x-rays is limited to bitewing and panoramic x-rays. Intraoral images are 
not covered. Therefore, we decided that the Plan does not have to pay for a comprehensive dental exam 
(D0150) and intraoral x-rays (D0220, D0230, D0350) provided March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services rendered from October 2, 2019 to October 7, 
2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the claims were not billed with the required modifier. 
 
The Plan must follow Medicare rules. The rules say that the required route of administration modifiers for 
dialysis services are JA, JB and JE. 
 
We looked at the file and Medicare rules. The file shows that the end-stage renal disease (ESRD) services will 
not billed with one of the required dialysis modifiers. 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 
pay for the services rendered from October 2, 2019 to October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 4, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.

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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 4, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve the pontics and retainer crowns for a fixed bridge.  
 
You asked the Plan to pre-approve the pontics and retainer crowns for a fixed bridge. You say that the 
temporary one is broken or cracked. You say that you are having difficulty chewing and need a permanent one. 
The Plan denied your request. The Plan says that the bridge is not medically necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. The Plan covers the pontics 
and retainer crowns for a fixed bridge when the services are medically necessary and reasonable. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the pontics and retainer crowns for a 
fixed bridge. Our reviewer says that the criteria for coverage has been met. Our physician reviewer found that 
the dental records and radiographs show the presence of an existing defective fixed bridge. Our reviewer says 
that it is reasonable to use a fixed bridge to replace the missing teeth rather than utilizing new crowns and a 
removable appliance. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the pontics and retainer crowns for a fixed bridge have been met. Therefore, we 
decided that the Plan has to pre-approve the pontics and retainer crowns for a fixed bridge.   
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI). 
 
You asked the Plan to pre-approve these services. You say that you can't do anything without increasing pain. 
The Plan denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that a lumbar ESI is covered when specific criteria 
are met. 
 
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 submitted records show that you 
have chronic low back pain. The records dated June 15, 2020 state that you have a spinal cord stimulator that 
has not been reprogrammed. There is no documentation of a trail of physical therapy. The criteria for coverage 
of the ESI are not met and the services are 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve iron sucrose injections. 
 
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 iron sucrose injections are covered when specific 
indications are present. 
 
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 based on the submitted records, the 
enrollee does not require dialysis for her chronic kidney disease and has not yet tried and failed oral iron 
supplementation or increasing iron-rich foods for her borderline iron-deficiency anemia. IV iron infusion is not 
indicated for this clinical situation and would only be reasonable if she were undergoing dialysis and had 
challenges with oral supplementation. Therefore, this request for iron sucrose injections will be considered not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve iron sucrose injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be requiring additional acute care services to help wean off 
mechanical ventilation. The patient does not require services at the LTACH that are not already being provided 
and available at the current facility. There are no services at the LTACH that the patient requires that are not 
already available and covered at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary at this time. Transfer may be considered at a later date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug infusion catheter supplies rendered on March 30, 
2020 to April 5, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no detailed written order. 
 
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating 
physician before dispensing any DMEPOS item to a beneficiary. 
 
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 pay for the drug infusion catheter supplies rendered on March 30, 2020 
to April 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the patient appears to be requiring additional short-term acute care services to help 
stabilize percutaneous endoscopic gastrostomy (PEG) tube function and see additional improvement in overall 
clinical status with the prednisone taper, however, the documentation does not suggest a need for more than 24 
days of acute care services. The patient does not require services at the LTACH that are not already being 
provided and available at the current facility. There are no services at the LTACH that the patient requires that 
are not already available and covered at the current facility. Therefore, this request for LTACH services will be 
considered not medically necessary at this time. Transfer to a lower level of care may be considered at a later 
date. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency department services (99283) 
provided May 29, 2020. 
 
You asked the Plan to waive the copayment for the emergency services. You say that you feel that you should 
not have to pay 2 copays for the ER visits. If the first hospital would have correctly diagnosed this properly you 
would not have had to drive all the way to the other hospital and be charged. The Plan denied your request. The 
Plan says the claim was processed correctly and the copayment applied per the plan benefits. 
 
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 $90 
copayment for emergency care.  
 
You have been asked to pay $90 copayment for the emergency services. The emergency services fall within the 
Emergency care 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 emergency 
department services (99283) provided May 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. The Plan states they did 
approve observation 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the work-up and monitoring in the emergency department (ED) prior to 
admission did not show an acute condition which might warrant inpatient acute care services. The patient 
required monitoring for a short while on the new Nadolol which would not likely take more than a two 
midnight stay in the hospital. 
 
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 not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
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 disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the 
hospital on September 12, 2020 with nausea, vomiting, a urinary tract infection, and a left buttock abscess. he 
is weak and deconditioned and is working with physical and occupational therapy. She is not walking due to 
weakness and poor balance and is minimum to moderate assist of two for transfers and maximum assist for 
most activities of daily living. Her endurance with therapy is noted to be poor. She is medically stable. She has 
no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. She may benefit from further therapy but does not require an intensive therapy program in 
an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Erbitux. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of 
metastatic head and neck cancer (squamous cell carcinoma of the right tonsil) that has previously been treated 
with surgeries, radiation and chemotherapy, Cetuximab and immunotherapy. He has been enrolled in a clinical 
trial that attempts to overcome Cetuximab-acquired resistance with the addition of Ficlatuzumab. The use of 
Erbitux (Cetuximab) with the addition of Ficlatuzumab has not been not been shown to be safe effective 
treatment that is medically reasonable and necessary for patients with metastatic head and neck cancer. The 
Erbitux is not safe and effective or reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Erbitux.