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

We decided that the Plan has to waive the copayment for the emergency room services (99282) and exchange 
nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, 
imaging guidance (50435x2) provided April 23, 2020 to June 8, 2020. 
 
You asked the Plan to waive the copayment for the hospital services. You say that you have provided copies of 
the bills you have received from the hospital. The Plan denied your request. The Plan says that this claim 
processed correctly. Your cost share was determined to be $836.38. You are covered by both Medicare and 
Medicaid. The provider must bill Medicaid directly after the plan has paid. 
 
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 enrollees must pay $0 copayment for in-network emergency services and $0 
copayment for in-network surgery services and $0 copayment for in-network diagnostic procedures and tests.  
 
The Plan says you must pay $836.38 for the hospital services. The plan applied $373.19 coinsurance for date of 
service 4/23/20, $90 copayment for date of service 05/22/20 and $373.19 coinsurance for date of service 
06/08/20. Based on the Plan contract, however, you cannot be asked to pay more than $0 copayment for in-
network emergency services and $0 copayment for in-network surgery services and $0 copayment for in-
network diagnostic procedures and tests. Therefore, we decided that the Plan has to waive the copayment for 
the emergency room services (99282) and exchange nephrostomy catheter, percutaneous, including diagnostic 
nephrostogram and/or ureterogram when performed, imaging guidance (50435x2) provided April 23, 2020 to 
June 8, 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: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Polivy. 
 
You asked the Plan to pre-approve Polivy. You say that the enrollee has received RCHOP and 2 different 
courses of radiation. The Plan denied your request. The Plan says that the documentation does not show that 
two previous systemic treatments have failed. 
 
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 Polivy. Our physician reviewer found 
that this request is for Polivy to be given with Bendamustine and Rituximab to treat relapsed diffuse large B-
cell lymphoma previously treated with chemotherapy and two rounds of radiation for relapse. Per the FDA, 
Polivy is indicated in combination with Bendamustine, and a Rituximab product is indicated for the treatment 
of adults with relapsed or refractory diffuse large B-cell lymphoma (DLBCL), not otherwise specified, after at 
least two prior therapies. The FDA label does not specify the prior therapies must be systemic. Radiation 
therapy is a therapy, and the enrollee has had both systemic and radiation therapy. The enrollee meets the FDA-
approved indication. Therefore, the documentation submitted supports that the drug as requested would be 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 Polivy have been met. Therefore, we decided that the Plan has to pre-approve 
Polivy.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical services to be provided at an out of network 
(OON) facility. 
 
You asked the Plan to pre-approve the surgical services to be provided at an OON facility. You say that you 
would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the OON surgeon is 
credentialed to perform the surgery at all of the alternative in-network facilities. The surgeon performing the 
surgery at the alternative in-network facility would be the OON surgeon as the enrollee has a referral. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the surgical services to be provided at an out of network (OON) facility.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Computed tomographic angiography (CTA). 
 
You asked the Plan to pre-approve Computed tomographic angiography. You say that you would like the plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested 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 Computed tomographic angiography. 
Our reviewer says that the documentation does not support that the requested services are not medically 
necessary. Our physician reviewer found the documentation includes a diagnostic limited ultrasound of the 
retroperitoneal aorta noting severe, hemodynamically significant stenosis of the bilateral common iliac arteries.  
The clinical indication for the ultrasound is stated as abdominal aortic aneurysm screening exam related to 
smoking history. CT angiography is recommended if clinically indicated. The records do not include a history, 
physical examination or any subjective data to support the medical necessity for the requested study. Therefore, 
the enrollee does not meet criteria for the requested 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 Computed tomographic angiography have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Computed tomographic angiography (CTA).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the crown (D2752) for tooth # 19 provided on 
May 19, 2020. 
 
You asked the Plan to reimburse you for the dental service. You say that this service was medically necessary. 
You say that you needed a crown to prevent further cracked tooth syndrome and hopefully eliminate further 
associated pain. You also say that you hope this crown prevents you from needing a future root canal or 
extraction. The Plan denied your request. The Plan says crowns are 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 reimburse you for 
the crown (D2752) for tooth # 19 provided on May 19, 2020.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation. 
 
You asked the Plan to pre-approve the stimulation. You say that this is medically necessary. The Plan denied 
your request. The Plan says the documentation does not show a trial of psychotherapy at the rate and length of 
time suggested to treat depression. 
 
 
 
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 stimulation. Our reviewer says that 
the requested stimulation is not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clear documentation of psychotherapy. There is no clear documentation of the 
enrollee's PHQ-9. It is unclear what medications are being taken during the present depression episode. 
 
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 stimulation have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcranial magnetic stimulation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have 
not been met. 
 
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 enrollee does not require services at the LTACH that are not available at the acute 
care hospital where he is currently receiving care. There are no services available at the LTACH that the 
enrollee requires that are not available at the health care setting being offered by the health plan. The requested 
LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of 
the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the medical services to be provided by an OON 
provider. 
 
You asked the Plan to pre-approve the medical services. You say that you are requesting review of denial of 
services. The Plan denied your request. The Plan says there are participating providers available to render the 
services. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the medical services to be provided by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heart stress test with imaging for the enrollee. 
 
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your 
request. The Plan says the information does not show why a regular stress test could not be done. 
 
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 imaging. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the enrollee has increased coronary risk but no documented cardiac symptoms and no documented 
ischemic electrocardiographic changes. In this circumstance the records do not support the medical necessity 
for nuclear stress testing. Screening stress testing is not indicated since it has not been shown to improve 
cardiac outcome 
 
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 imaging have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a heart stress test with imaging for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Zoster (shingles) vaccine provided on January 24, 2020 
and May 22, 2020. 
 
You asked the Plan to pay for Zoster (shingles) vaccine (90750, 90472, 90471). You say that you do not want 
to pay for this vaccine. The Plan denied your request. The Plan says this vaccine is not covered under your 
Medicare Part B benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Zoster (shingles) 
vaccine (90750, 90472, 90471). The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to Zoster (shingles) 
vaccine (90750, 90472, 90471). Therefore, we decided that the Plan does not have to pay for the Zoster 
(shingles) vaccine provided on January 24, 2020 and May 22, 2020.  
 
Benefits for Zoster (shingles) vaccine (90750, 90472, 90471) may be available under Medicare Part D. Contact 
the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient lab work provided by a 
participating provider on July 27, 2020. 
 
You asked the Plan to waive the copayment for outpatient lab work. You say that this was part of your annual 
wellness exam. 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 $10 
copayment for outpatient diagnostic tests/in-network/labs.  
 
You have been asked to pay a $10 copayment for outpatient lab work. Lab work goes beyond an annual 
wellness exam; therefore, the correct copayment has been applied. Outpatient lab work falls within the 
outpatient diagnostic tests/in-network/labs 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 outpatient lab work provided by a participating provider on July 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the denture adjustment (D5520) provided on June 18, 2020. 
 
You asked the Plan to pay for the dental service. You say that you were told that the plan pays 70%. You also 
say that you pay $20 a month for coverage. The Plan denied your request. The Plan says this service is dental in 
nature. The Plan also says denture adjustments are not 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 pay for the 
denture adjustment (D5520) provided on June 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary, rest home visit provided on December 19, 
2019. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the domiciliary, rest home visit provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation provided on July 14, 
2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that you are supposed to have a $15 
copayment for comprehensive oral exams. You say that you shouldn't be responsible for the $70 amount. The 
Plan denied your request. The Plan says you are only eligible for a comprehensive oral exam once every 36 
months. 
 
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, you also have a maximum benefit of 
one comprehensive oral evaluation every 36 months. The Plan paid for a comprehensive oral evaluation 
provided on July 22, 2019, which exhausted your benefit. Therefore, we decided that the Plan does not have to 
pay for the comprehensive oral evaluation provided on July 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve praluent 75 mg/ml pen. 
 
You asked the Plan to pre-approve praluent 75 mg/ml pen. You say that it is medically necessary. The Plan 
denied your request. The Plan says your plan has Part A and Part B coverage, with no Part D drug coverage. 
Medicare says Part B programs can only provide limited benefits for prescription drugs. 
 
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 praluent 75 mg/ml pen.  
 
Benefits for praluent 75 mg/ml pen may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
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 therapy needs can continue to 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of residual tooth roots. 
 
You asked the Plan to pre-approve the removal of residual tooth roots. 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. 
 
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 
removal of residual tooth roots.