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

We decided that the Plan does not have additional routine transportation mileage. 
 
You asked the Plan the additional miles. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested trip is 53.1 miles one-way. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation up to 30 miles one-way. 
 
We looked at your request, the records in the case file, and the rules. The requested trip is over the plan's 
mileage limit. Based on this information, we decided that the Plan's rules for coverage of routine transportation 
have not been met. Therefore, we decided that the Plan does not have additional routine transportation mileage.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an automatic blood pressure monitor. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary, as your low blood 
pressure affects your kidneys to stop functioning. The Plan denied your request. The Plan says this is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 
setting. 
 
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. Long term 
acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide 
clinical services that are materially different than those of short term acute care hospitals. The enrollee is 
receiving acute hospital care, and acute care services have not been denied. The documentation does not 
support that the enrollee in this case requires services at the LTACH that are not available at the acute care 
hospital where he is currently receiving care. The documentation does not support that an additional 25 days of 
hospitalization are reasonably expected for the enrollee in this case. Our physician reviewer found that the 
enrollee's condition does not meet Medicare criteria for LTACH services. 
 
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 long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and excision of benign 
lesion (D7410) provided on July 2, 2020. 
 
You asked the Plan to pay for the limited oral evaluation and excision of benign lesion. You say that these 
services were coded incorrectly. The Plan denied your request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation 
(D0140) and excision of benign lesion (D7410) provided on July 2, 2020.  
 
Your complaint about the potential coding of services error is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda. 
 
You asked the Plan to pre-approve the Keytruda. You say that the records provided support the need for the 
requested drug. The Plan denied your request. The Plan says the clinical criteria for coverage have not been 
met. 
 
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 the Keytruda. Our reviewer says that 
the criteria for coverage have not been met. Our physician reviewer found Keytruda is not FDA approved for 
the enrollee's diagnosis. Our physician reviewer found that the use of this drug is not supported by one of the 
major drug compendia or by clinical research that appears in a CMS-approved medical journal. 
 
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 Keytruda have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan has to pre-approve a Medicare-approved CGM. We decided that the Plan does not 
have to pre-approve the Minimed Guardian CGM. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
says that the Minimed Guardian is not a Medicare-approved CGM. 
 
We decided that the Plan has to pre-approve a Medicare-approved CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM 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 enrollee meets the criteria for coverage of a therapeutic CGM. Our physician reviewer found the enrollee is 
diabetic and uses an insulin pump. He has been using a CGM and is performing blood glucose level checks 
multiple times per day. The records support that the criteria for coverage are met and the CGM is medically 
necessary. The records do not support that the specific brand of requested CGM sensors is 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 Medicare-approved CGM have been met. Therefore, we decided that the 
Plan has to pre-approve a Medicare-approved CGM.  
 
We also decided that the Plan does not have to pre-approve a Minimed Guardian CGM. 
 
The services at issue are a Minimed Guardian CGM. This brand is not a Medicare-approved CGM and is not 
covered. The enrollee may receive a Dexcom G5, Dexcom G6, FreeStyle Libre 14 day, or FreeStyle Libre 2 
CGM. Therefore, we decided that the Plan does not have to pre-approve a Minimed Guardian CGM. 
 
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 sacroiliac (SI) joint radiofrequency ablation (RFA). 
 
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. 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 services are not medically necessary. Our physician reviewer found SI joint ablation is considered 
experimental in nature. More research is needed to show safety and efficacy The use of RFA for sacroilitis has 
not been shown to provide clear long-term benefit than standard treatment for chronic sacroiliac joint pain. The 
services are 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 sacroiliac (SI) joint radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (CPT Codes: 33289 and 
C2624). 
 
You asked the Plan to pre-approve the device. You say that the device is necessary. The Plan denied your 
request. The Plan says this service is considered experimental and investigational. The Plan states the member 
has not been enrolled in an approved category B investigational device exemption (IDE) study. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time. Further 
clinical study is needed to determine the efficacy and safety of this device. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve the CardioMEMS device (CPT Codes: 33289 and C2624).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 1, 2020. 
 
You asked the Plan to pay for the laboratory 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 are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
 
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D2954).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this 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.

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 dental services (D2954).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body (D6010) and semi-
precision attachment abutment (D6052). 
 
You asked the Plan to pre-approve surgical placement of implant body and semi-precision attachment 
abutment. You say that these services are necessary. The Plan denied your request. The Plan says these services 
are not covered by the Plan's supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
surgical placement of implant body (D6010) and semi-precision attachment abutment (D6052).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on 
September 24, 2019 by an out of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care services. 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. 
 
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 subsequent nursing facility care services 
provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hydroco/Apap tab 10-325mg for the enrollee. 
 
You asked the Plan to pre-approve the tablet. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not a covered benefit. 
 
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 Hydroco/Apap tab 10-
325mg for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultra-lightweight wheelchair, and related accessories. 
 
You asked the Plan to pre-approve the requested wheelchair. You say that the use of a cane or walker has been 
ruled out. The Plan denied your request. The Plan says the wheelchair is not a covered benefit while the 
enrollee is residing at the nursing facility. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the requested wheelchair is being requested for use in a SNF. Therefore, we decided that the 
Plan does not have to pre-approve an ultra-lightweight wheelchair, and related accessories.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from August 9, 2020, to 
August 17, 2020 billed with ICD-10 procedure code 037G3ZZ. 
 
You asked the Plan to pay for the inpatient services as billed. You say that this is correctly billed and should be 
paid at the reported DRG. The Plan denied your request. The Plan says this claim was correctly denied since it 
was billed with a noncovered procedure. 
 
The Plan must follow Medicare rules. Medicare rules say that the MCE checks the procedure codes reported on 
the claim and returns to provider if one is not valid.  
 
In this case, in the 2020 version (V37.2) of the Definition of Medicare Code Edits, ICD-10 procedure code 
037G3ZZ is listed as noncovered. Therefore, we decided that the Plan does not have to pay for the inpatient 
hospital care provided from August 9, 2020, to August 17, 2020 billed with ICD-10 procedure code 037G3ZZ.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chemical cauterization of granulation tissue services 
provided on July 22, 2020, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the chemical cauterization of granulation tissue services. You say that you would 
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a 
covered benefit. 
 
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 chemical cauterization of granulation tissue 
services provided on July 22, 2020, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the external infusion pump provided on February 17, 2019. 
 
You asked the Plan to pay for the external infusion pump. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this is not separately payable as these 
infusions were started in a physician's office. 
 
The Plan must follow Medicare rules. Medicare rules say that equipment used to infuse drugs when the 
infusion is started in the physician's office are not separately billable as durable medical equipment. 
 
We looked at the file and Medicare rules. In this case, you are requesting payment for an external infusion 
pump. The file shows that the enrollee begins infusion with the pump in the doctor's office. As such, separate 
payment for the equipment is not allowed. Therefore, we decided that the Plan does not have to pay for the 
external infusion pump provided on February 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Optune tumor treating field electrical therapy 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 the safety/efficacy of Optune for grade III glioma has not been established. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is no diagnosis of glioblastoma. The diagnosis is of a grade III astrocytoma. 
 
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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Optune tumor treating field electrical therapy for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve high intensity focused (HIFU) ultrasound ablation of the 
prostate (CPT Code 55880). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the Medicare rules have not been 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 the services. Our physician reviewer 
found high-intensity focused ultrasound (HIFU) uses sonic waves to create thermal energy that destroys the 
target tissue within the prostate. HIFU has not been compared with other standard treatment approaches in 
randomized trials, nor is it included in guidelines for the initial management of men with prostate cancer. 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve high intensity focused (HIFU) ultrasound ablation of the prostate (CPT Code 55880).
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Armodafinil 150MG tab. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the service or item requested is not covered under the member?s plan under any 
normal circumstances. The Plan states the medication falls under Part D coverage, but the member has no Part 
D pharmacy benefit. 
 
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 Armodafinil 150MG tab.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.