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

We decided that the Plan does not have to pre-approve Entyvio for the enrollee. 
 
You asked the Plan to pre-approve Entyvio. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that Entyvio is considered experimental and investigational for collagenous 
colitis. 
 
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 Entyvio. Our reviewer says that 
Entyvio is not medically reasonable and necessary for the enrollee in this case. Whereas recent low-volume 
case testimonials have highlighted in a few individuals the potential for Entyvio as a steroid-sparing option for 
refractory microscopic colitis, the enrollee's symptoms are likely of multifactorial etiology. It is neither likely 
that her microscopic colitis is steroid-refractory (available records do not support recent corticosteroid 
responses), nor that targeting only the microscopic colitis aspect of her symptoms with off-label use of Entyvio 
is either medically necessary nor likely to result in greater benefit than harm in her situation. Our physician 
reviewer found the enrollee's condition does not meet Medicare criteria for Entyvio. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Entyvio for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing provided on September 11, 2019. 
 
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory 
requisition form. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the documentation submitted does not support the lab tests billed. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific 
lab services is required for covered lab services.  
 
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician 
order or clear intent to order the specific lab services billed on this claim. Based on this information, we 
decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan 
does not have to pay for drug testing provided on September 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy (D3320) provided on January 30, 2020. 
 
You asked the Plan to pay for endodontic therapy (D3320). You say that the dentist was able to save the tooth 
and avoid extraction. You say that you should be reimbursed. 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 pay for 
endodontic therapy (D3320) provided on January 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473). 
 
You asked the Plan to pre-approve the removal of torus mandibularis (D7473). You say that treatment should 
be authorized as it 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. 
 
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 torus mandibularis (D7473).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation 
to attend medical appointments. The Plan denied your request. The Plan says you have exceeded your benefit 
limit. 
 
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 a maximum of sixty (60) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on January 30, 2020 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the outpatient visit (G0467 and 99214) provided on January 30, 2020.. You say 
that you would like reconsideration because you should be paid at least the Original Medicare rate. The Plan 
denied your request. The Plan says no medical necessity for out-of-network services has been documented and 
there are network providers available. 
 
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 medical services provided on January 30, 2020 
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 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 
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the skilled 
nursing facility (SNF) on July 2, 2020 with cellulitis and venous thrombosis of both lower extremities. He is 
walking 20 feet with a wheeled walker with minimum assistance and needs contact guard assistance with 
transfers and activity of daily living. He is medically stable. The complexity of his nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. He does require physical therapy and occupational therapy services but, based on the 
medical records provided, does not require an intensive inpatient rehabilitation therapy program. 
 
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 surgical extraction (D7210) for tooth #10. 
 
You asked the Plan to pre-approve the surgical extraction (D7210) for tooth #10. The Plan denied your request. 
The Plan says the documentation submitted does not support the code requested. 
 
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 surgical 
extraction (D7210) for tooth #10 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 surgical extraction of erupted tooth 
(D7210) for tooth #10. Our reviewer says that the surgical extraction is not medically necessary. Our physician 
reviewer found that bone removal and elevation of a mucoperiosteal flap is not required for the removal of 
tooth #10.  
 
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 surgical extraction (D7210) for tooth #10 have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the surgical extraction (D7210) for tooth #10.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission. 
 
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 admission is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is 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 
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the hospital 
on July 27, 2020 with congestive heart failure, chronic obstructive pulmonary disease, and diabetes. He 
received oral and inhaled medications and insulin and had stable vital signs. He received physical and 
occupational therapy in the hospital and needs moderate to maximum assist with functional mobility, including 
gait. He needs varied assist with activities of daily living. He has no skilled nursing needs. He has skilled 
therapy needs but does not require skilled therapy on a daily basis. As a practical matter, the enrollee does not 
require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (CPT 80307 and HCPCS G0483) 
provided to the enrollee on May 1, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical 
records (signed by the ordering physician); therefore, the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes are: 
 
CPT 80307: 
 
Drug test(s), presumptive, any number of drug classes, qualitative; any number of devices or procedures, by 
instrument chemistry and analyzers (e.g., utilizing immunoassay [EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), 
chromatography (e.g., GC, HPLC), and mass spectrometry either with or without chromatography, (DAT, 
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when 
performed, per date of service 
 
HCPCS G0483: 
 
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and 
distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms 
(any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, 
elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally 
recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in 
signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., 
to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes 
specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed  
 
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 services. Our reviewer says that the 
services at issue in this case were supported by the medical records submitted. Our physician reviewer found 
the review has determined that the documentation submitted did not include a valid physician order/lab 
requisition or medical records (signed by the ordering physician); therefore, the billed codes cannot be verified. 
 
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 pay for drug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on May 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 29, 2019 by an out 
of network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like reconsideration 
because the services rendered were medically necessary. The Plan denied your request. The Plan says this 
member does not have out-of-network benefits. 
 
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 medical services provided on August 29, 2019 
by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services at a comprehensive outpatient rehabilitation 
facility (CORF). 
 
You asked the Plan to pre-approve these services. You say that you need therapy. The Plan denied your 
request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that CORF services are 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 records show that you were 
hospitalized on August 3, 2020 with complaints of six falls and weakness for two weeks. You have a urinary 
tract infection (UTI) and the multiple sclerosis is considered stable. You do not have a condition that requires 
prehensive outpatient diagnostic, therapeutic, and restorative services provided by or under the direct 
supervision of a physician in a CORF setting. While you would benefit from physical therapy, you are at a 
functional level that does not require speech/language therapy, respiratory therapy, or social work. The CORF 
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 services at a comprehensive outpatient rehabilitation facility (CORF).
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a CT scan of the chest. We decided that the Plan does not have to 
pre-approve services from an out-of-network provider. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
says that the services are not medically necessary. 
 
We decided that the Plan has to pre-approve a CT scan of the chest. 
 
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 of the chest. Our reviewer 
says that the services are medically necessary. Our physician reviewer found the enrollee has stage IV 
squamous cell carcinoma of the glottis. A CT scan of the chest as surveillance is medically necessary. Accurate 
interpretation of CT is necessary to differentiate between post-treatment and residual or recurrent disease. 
Baseline CT or MRI performed three to six months after treatment should be obtained, especially in high-risk 
advanced state patients. These modalities can be very useful in drawing a comparison with subsequent imaging 
for earlier detection of recurrent/residual disease. The CT scan is reasonable and medically necessary. The Plan 
has network providers available to provide the services; therefore, the referral to the out-of-network provider is 
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 the CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a computed tomography (CT) scan of the chest. Therefore, we decided that the Plan has to pre-approve 
a CT scan of the chest. 
 
We also decided that the Plan does not have to pre-approve services from an out-of-network provider. 
 
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. Therefore, we decided that the Plan does not have to pre-approve services from an out-of-network 
provider. 
 
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: ER
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the emergency room visit. We decided that the Plan 
does not have to waive the copayment for inpatient hospital stay.  
 
You asked the Plan to waive the copayment for the emergency room visit and the inpatient visit. You say that 
you should not be responsible for the $120 copayment because you were admitted twice within a 24-hour 
window for the same condition. The Plan says that you have been charged the correct cost sharing amount. 
 
 
We decided that the Plan has to waive the copayment for the emergency room visit.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not submit the medical records to show that the enrollee was 
admitted to the emergency room and admitted as an inpatient for unrelated conditions. Therefore, we decided 
that the Plan has to waive the copayment for an emergency room visit. 
 
We also decided that the Plan does not have to waive the copayment for inpatient hospital stay. 
 
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 $200 
copayment for and the inpatient visit. Therefore, we decided that the Plan does not have to waive the 
copayment for inpatient hospital stay. 
 
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.